Insert “Pharmacist” where it mentions “Nurse Practitioner” The Pharmacist as Primary Care Provider

Jp Enlarged

Pharmacists will be providing primary care.  Maybe not you and certainly not me, but there are plenty out there who are well educated and up to the task.  The powers at the bugaboo “The Affordable Care Act” are looking at you and nurses.  It just makes good sense.  Either you and Nurse Practitioners or millions get no primary care at all.

Dr. Pauline Chen on medical care.

Not long ago, I attended a meeting on the future of primary care. Most of the physicians in the room knew one another, so the discussion, while serious, remained relaxed.

Toward the end of the hour, one of the physicians who had been mostly silent cleared his throat and raised his hand to speak. The other physicians smiled in acknowledgment as their colleague stood up.

“Nurse practitioners,” he said. “Maybe we need more nurse practitioners in primary care.”

Smiles faded, faces froze and the room fell silent. An outraged doctor, the color in his face rising, stood to bellow at his impertinent colleague. Others joined the fray and side arguments erupted in the back of the room. A couple of people raised their hands to try to bring the meeting back to order, but it was too late.

The physician had mentioned the unmentionable.

I remembered the discord and chaos of that meeting when I read a recent study in The New England Journal of Medicine of nurses’ and physicians’ opinions about primary care providers.

For several years now, health care experts have been issuing warnings about an impending severe shortfall of primary care physicians. Policy makers have suggested that nurse practitioners, nurses who have completed graduate-level studies and up to 700 additional hours of supervised clinical work, could fill the gap.

Already, many of these advanced-practice nurses work as their patients’ principal provider. They make diagnoses, prescribe medications and order and perform diagnostic tests. And since they are reimbursed less than physicians, policy makers are quick to point out, increasing the number of nurse practitioners could lower health care costs.

If only it were that easy.

Three years ago, a national panel of experts recommended that nurses be able to practice “to the full extent of their education and training,” leading medical teams and practices, admitting patients to hospitals and being paid at the same rate as physicians for the same work. But physician organizations opposed many of the specific suggestions, citing a lack of data or well-designed studies to support the recommendations.

In an effort to build consensus, the Robert Wood Johnson Foundation then invited a dozen leaders from national physician and nursing groups to discuss their differences. The hope was that face-to-face discussions would help physicians and nurses understand one another better and see beyond the highly charged and emotional rhetoric. The approach worked, at least initially; after three meetings, the group drafted a report filled with suggestions for reconciling many of the differences.

But an early confidential draft was leaked to the American Medical Association, a group that had not been invited to participate, and the A.M.A. immediately expressed its opposition to the report. Soon after, three of the participating medical organizations — the American Academy of Family Physicians, the American Osteopathic Association and the American Academy of Pediatrics — withdrew their support, and the effort to bring physicians and nurse practitioners together and complete the report collapsed.

Nonetheless, many health care experts remained confident, believing that the large professional organizations had grown out of touch with grass-roots-level health care providers. The guilds might oppose one another, but every day in medical practices, clinics and hospitals across the country, physicians and nurse practitioners were working side by side without bickering. Surely, the experts reasoned, providers who knew and liked one another would be receptive to trying new ways of working together.

Wrong.

Analyzing questionnaires completed by almost 1,000 physicians and nurse practitioners, researchers did find that almost all of the doctors and nurses believed that nurse practitioners should be able to practice to the full extent of their training and that their inclusion in primary care would improve the timeliness of and access to care.

But the agreement ended there. Nurse practitioners believed that they could lead primary care practices and admit patients to a hospital and that they deserved to earn the same amount as doctors for the same work. The physicians disagreed. Many of the doctors said that they provided higher-quality care than their nursing counterparts and that increasing the number of nurse practitioners in primary care would not necessarily improve safety, effectiveness, equity or quality.

A third of the doctors went so far as to state that nurse practitioners would have a detrimental effect on the safety and effectiveness of care.

“These are not just professional differences,” said Karen Donelan, the lead author of the study and a senior scientist at the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston. “This is an interplanetary gulf,” she said, echoing a point in an editorial that accompanied her study.

The findings bode poorly for future policy efforts, since physicians are unlikely to support efforts to increase the responsibilities and numbers of advanced-practice nurses in primary care. And most nurse practitioners are unlikely to support any proposals to expand their roles that do not include equal pay for equal work.

Peter I. Buerhaus, senior author of the study and a professor of nursing at Vanderbilt University Medical Center in Nashville, is chairman of a commission created almost three years ago under the Affordable Care Act to address health care work force issues. But his group has yet to convene because a divided Congress has not approved White House requests for funding.

“We’re running out of time on these issues,” Dr. Buerhaus said. “If the staffing differences remain unresolved, we are just going to cause harm to the public.”

Still, by providing a clearer picture of the extent of these professional differences, the study should help future efforts. “It’s too easy to say that everyone should just get along,” Dr. Donelan said. “These arguments touch on the whole nature of these professions, their core values and how they define themselves.”

“It’s like when family members are warring over a sick patient,” she added. “We need first to acknowledge the others’ position and the full extent of our differences before we can reach any kind of resolution.”

From a Comment Made by PharmacySlave2000.

 I see the AMA fighting to the death to hold on to their place at the top of the food chain. They MAY agree to let NP’s or PA’s take the lead under their watch but there is no way they are going to let pharmacists have any piece of that pie.

Jay Pee’s take, PharmacySlave2000, It will not be up to THEM.  The AMA got all the power with The Durham-Humphrey Amendment.  The first job of the AMA is to protect turf.  At every turn, the AMA said that pharmacists are not good enough.  Pharmacist counseling was interference with the doctor-patient relationship.   Then, in the 1970s, pharmacists were given  ”Drug Product Selection” discretion.  That was simply which brand to dispense.  Achromycin V, Tetracyn, Sumycin or simply Tetracycline HCl.  The AMA squealed, “You can’t give pharmacists discretion like that.  Patients will be harmed. Yama, Yama, Yama.”  At the same time, they are checking the winter rentals at  their ski chalet at Squaw Valley.   The third class of drugs.  The “Behind the Counter Class” to be sold only with a pharmacist supervising.  Believe it or not, the slow-moving machine of the APhA was all for this.  William S. Apple (APhA President at this time-1970s) went full-frontal.   He wrote numerous articles promoting the Third Class of Drugs.  He made personal appearances from the seat of President of the APhA.  Those of us pharmacists who watched and could see how our profession could benefit financially and professionally were salivating in the stands.  William S. Apple was truly an American Pharmacy hero.   He led the APhA in a manner that kept that huge professional organization focused on the way pharmacists practiced as well as how our profession could help patients.  Monistat Vaginal Cream sold OTC is ridiculous.  Aunt Sally’s diagnosis of a “Yeast Infection” could cause Niece Brenda to buy Monistat and happily believe she will be cured.  The bacteria in that warm moist place proliferates.  Next is PID and she will never be able to have children.  William S. Apple was right on.  It looked very good.  My friends and I did buy the champagne and the big cigars.   The AMA came in late, but they came in  hard.  ”This 3rd party class is practicing medicine without a license.”  No assholes, it is practicing pharmacy WITH a license.  What does the AMA have against us.  You know and I know that modern pharmacists can easily be a primary care provider and a superior prescriber.  We won’t do surgery.  We don’t want to.  That is your job, Buster.  Patient care, that’s the nurse’s job.  The real reason that the AMA is afraid of pharmacists is because we hold the keys to the kingdom.  Modern medical care IS DRUGS.  Can’t you get that?   The AMA is desperate that CMS not recognize us as independent practitioners with discretion.   They fought like hell to make pharmacists not eligible to be paid directly for services rendered.  CVS fought like crazy.  They even approached the BOP in Massachusetts and challenged pharmacists having their own NPI.  The AMA fought against us being allowed to have NPIs.   Let us go back 60 years to the days before Durham-Humphrey.  This was the peak of the era of the DRUGGIST.  I was a kid, working at Cook Drug on Main Street.  I watched patient’s come in and present their problem.   The Druggist got them a drug for it and they were usually thrilled.  I have no idea what he gave (Actually, I do know one remedy) them.  These people chose “Doc”, the Druggist.  They knew that “Doc” could help them without needles and scalpels.   The doctor usually hurt them and they often did not get better.  An example from way back.  And this shit happened near the first part of the 20th Century.  An older farmer worked hard to get the harvest in.  The physical result was serious pain.  Back, muscular, hip.  The nearest town was 50 miles away.  There was a Drug Store, run and owned by the Druggist.  The doctor was around the corner.  He had been to the doctor many times, taken himself or a hand who had hurt themselves.  They needed wounds cleaned and stitched, but just pain.  He would always go to the Druggist.  Why (remember.. way back)?  Because the Druggist would give him a sickening-tasting elixir that contained cocaine.  No more pain.  No contest.  ”Doc”, the Druggist was the main man in that town.

I do not know what the politics was like near the end of the 1940s.  Coming up with Prescription-Only and OTC classes cleared the track for medical doctors to run the medical care train.  Pharmacy was relegated to the back of the bus where just about our entire job was dispensing.  Think about it.

Then, think about this.  You haters of Barack Obama most likely do not have problems with The Affordable Care Act. Get on board with Obamacare. It can save pharmacy’s ass.  The brains who are designing the new system have already acknowledge in the media that pharmacists (with Pharm D) and nurses (with advanced degrees) are well enough educated to provide primary care.  It will happen for only one reason.  You and nurses are cheaper than doctors.  Basically, you guys, Obamacare has thrown the gauntlet at the AMA.  ”Show us proof that we cannot trust pharmacists and nurses to see patients or fuck you.”  It will be “Fuck You” to the AMA.  Young doctors don’t give a shit.  They are team conscious and they are happy to get relief.  An orthopedist does not need an appointment slot taken up by a weekend tennis player with a hyper-extended knee.  The pharmacist can do that.  And..he can get paid directly for it.

This is going to happen wicked fast.  Those of you who take the advice of The Goose will have a rewarding career.  Those of you who just want to dispense…Well, what the hell… CVS is gonna need RPhs to keep the metrics green.  You will be a robo-dispenser, some kind of fairy phantom pharmacist.  A grossly over-educated Advanced Technician.

I keep on insulting you guys on this and you take it.  What the fuck?  Where is your pride?   Tell me I am full of shit and give me evidence.  Remember, when you go after me, you are going after Goose and my tribe.

 William S. Apple ..Pharmacist First..Always

15 Comments

15 Comments

  1. goose  •  Jun 28, 2013 @11:55 am

    JayPee is right. If you are young or are planing to practice for the next 20 years, you need to get the skills to do more than dispense.
    There has never been more of a need for DUR analysis than there is now, it can literally save thousands of dollars per patient in some cases. Only pharmacists do this well in my opinion.
    The catch is, you need additional training. I would highly recommend that if you are going to practice pharmacy in the future, that you become board certified in either pharmacy practice or a speciality like geriatrics or anticoagulation.
    Yeah, it’s hard. Yeah, you have to learn a new skillset. But I’ll tell you, it will be more valuable than a residency.
    If you just want to dispense, soon you will either be un-employed or a third-class citizen in the new healthcare world.
    Remember, if you’re not at the table, you’re on the table.

  2. bluetowelboy  •  Jun 28, 2013 @4:25 pm

    Won’t happen anytime soon but how hard can it be to train a small group of pharmacists to take blood pressure and basic stats. We already know how to read test results if we could order them we could make adjustments to patient therapy. I’m sure we could learn basic diagnostic skills like nurse practitioners and act as the first stop for patients and make sure the more severe cases were forwarded to physicians. We basically triage now just at a lower level.

    There is going to be a severe shortage of first line practitioners in the coming years. First step is getting someone to fund a study to show we can do it. Probably a government service like VA or Indian health service. Someone get on it. Even if it was an extra year of training they could incorporate it into the already bloated pharmD but keep the years the same. It would be too late for me as this sort of stuff moves slow but I totally could see us moving in that direction.

  3. pharmacyslave2000  •  Jun 28, 2013 @4:52 pm

    There will be many others in line for this before pharmacists. These other healthcare workers (PA’s, NP’s, RN’s, etc.) function, in at least a small capacity, as autonomous professionals. They are allowed to prescribe meds., read charts, dictate care, without any additional training. They’re ready to go right out of the box. They work in environments where their expertise is needed and utilized. On the other hand, we are employees of corporations. We are in charge of a product because an antiquated law says that we have to be. We have no autonomy and most of our “patients” don’t care what we know or what we are capable of. We would need additional training to get up to speed on true patient care. I agree with Goose’s comment, “If you just want to dispense, soon you will either be un-employed or a third-class citizen in the new healthcare world” but I don’t think we’ll have any real say in the direction our profession takes. We may end up even farther down the new healthcare totem pole.
    ***
    I see the AMA fighting to the death to hold on to their place at the top of the food chain. They MAY agree to let NP’s or PA’s take the lead under their watch but there is no way they are going to let pharmacists have any piece of that pie.

  4. impatient  •  Jun 28, 2013 @9:14 pm

    Pharmacists know way more than most MDs about what to prescribe for which conditions, drug interactions, and maybe combinations of drugs that work well together for conditions that require same (I go to a shrink to treat a long term combination of related problems that require occasional tweaks. We agreed 3-4 years ago to stick with generics after a couple bad experiences with new drugs that were being sampled.) I’d certainly visit my pharmacist for primary care, especially if you could order one interpret labs – your hours are a lot more convenient.

  5. broncofan7  •  Jun 29, 2013 @8:06 pm

    I love the historical perspective that JP offers. It is much appreciated by this Pharmacist in his 30′s. (incidentally JP, I took the family on a vacation to Galveston a few weeks ago and we had a great time!–lots of new expensive houses being built the further south you go on the island too)

  6. broncofan7  •  Jun 30, 2013 @8:18 am

    http://allnurses.com/nurse-practitioners-np/states-nps-can-209418.html

    This really needs to be updated and stickied. Looking at my notes and the ACNP site here are the states that NP’s can practice without any physician involvement (please post any corrections here):
    Arizona
    Alaska
    Idaho
    Iowa
    Montana
    New Hampshire
    New Mexico
    Oregon
    Wyoming

    The following states require a collaboration agreement to prescribe:
    Colorado
    Michigan
    New Jersey
    North Dakota
    Oklahoma
    Rhode Island
    Tennesee
    West Virginia

    Maine requires two years supervised experience prior to independent practice.

    The following states are unclear reading their nurse practice act
    DC – supervision to prescribe but may be by an NP?
    Hawaii – Appropriate working relationship with a physician (defacto collaboration?)
    Utah – Consulting relationship – requires physician license and DEA – seems to be the same as collaboration agreement?

    Note that a number of states require either time as an NP or additional pharmacology classes to prescribe. Also some states have fairly restrictive formularies for NP’s which may or may not be regarded as unrestricted practice.

  7. broncofan7  •  Jun 30, 2013 @8:21 am

    also, to bill Medicare and Medicaid a NP or PA must have a supervising physician in order to bill those two government insurance entities. So as you can see, getting PROVIDER status is just the first of MANY steps that Pharmacists will need to take and NBP’s and PA’s are already way ahead of us both in recognition and in the practice of medicine

  8. broncofan7  •  Jun 30, 2013 @8:24 am

    To Pharmacyslave2000′s point…NP’s and PA’s ARE IN FACT more readily positioned to step in an fill the Primary Care hole that so many are speaking of in the media. Need a REAL LIFE EXAMPLE? Here is what is going on in Nevada now…http://www.lasvegassun.com/news/2013/feb/28/legislation-would-let-nurses-practice-independentl/#axzz2XhlXYu00

    Pharmacists are NO WHERE on the radar for prescriptive authority; we are still fighting for recognition as providers. That being said, I do want to FIGHT for it. However in the near future, Pharmacyslave is correct. Perhaps when he an I are in our mid 50′s the scope of Practice for Pharmacy may change, but it will be another generation of Pharmacists who get to partake in that.

    As a side note, although 16-20 states currently allow Nurse Practitioners to practice independent of physician’s; it’s the INSURANCE companies who determine the true viability of their business model and the MAJORITY of insurers still do not pay NP’s at a rate commensurate with practice sustainability.

    We are at least 1 full lap behind them in any attempt to acquire those professional responsibilities despite the fact that I feel as though we should have front line prescriptive authority for everything from AR,URI,UTI, Lipid control and non complicated BP control. Once they are seen by a Pharmacist provider, we would then make referrals to Physician/NP offices which would then truly define our role as the entry point into the healthcare system.

  9. Pharmaciststeve  •  Jun 30, 2013 @10:44 am

    @Bronco…
    You are correct.. as long was we are geographically separated from the typical prescriber’s environment.. we are most likely never going to get prescriptive authority.. We may get some latitude in requesting labs and adjusting doses.. like RPH’s do in anti-coagulant clinics..

    Working in LTC.. I routinely – at least indirectly – order labs… and adjust doses particularly on IV antibiotics..

    Working in LTC.. we have a handful or so of the same doc/medical directors that we work with.. we are on a first name basis.. there is a certain level of trust that has evolved..

    I see consultant reports .. where drugs/doses changes are recommended.. I would say that 95%+ are accepted by the prescriber…

    I am see a lot more ARNP, NP, PA seeing pts in LTCF.. working under the doc or the medical director..

    I have worked in in-house pharmacies and my own pharmacy was in a small town.. and in those environment.. again.. a certain level of trust evolves and a great deal of latitude in dealing with pts.. happens.. everyone is focused on what is best for the pts..

    In larger cities or in chain pharmacies where the RPH’s keep rotating.. that level of trust with the prescriber.. never evolves..

    As long as RPH’s remains geographically segregated … not much progress will be made.. Obamacare could end up being pharmacy’s friend.. first the forecast of a shortage of primary care prescriber and the ACO’s primary function will be to keep people out of the hospital.. and see that the pt has the best drug therapy at the lowest cost,.. that is going to involved compliance and maybe a closer relationship with a healthcare professional.. that may/could be the local RPH.. We may end up with the ACO’s granting us a certain degree of pt therapy management control.. like the VA and the Native American Health Service does. I think that the ACO will be in the position to accept responsibility/liability for doing so.

  10. Goose  •  Jul 1, 2013 @9:53 am

    The one thing a pharmacist brings to the table in my opinion is that we are trained to evaluate a situation quickly, know where to get the necessary information and make a rapid judgement that is usually right on the money.
    Most medical professionals just don’t do that. Because of our work environment, we either have those skilss or are in a different profession.
    I have no doubt that with a minimal amount of training, we could run rings around a PA or NP, I know, I’ve worked with them. Most of them know a little about most things and not a lot about anything. They only use a few drugs and antibiotic stewardship is off their radar. They just kind of diagnose and throw drugs at everything.
    Our biggest advantage is our communication skills, nobody else in the health iz is even close.
    I think an EMT trained pharmacist could do it.
    Good discussion though.

  11. Peon  •  Jul 1, 2013 @10:33 am

    Goose is right about NP’s. We pharmacists are trained to quickly evaluate a situation and make a judgment, and most NP’s ‘know a little about most things and not a lot about anything’. In my opinion, they are just not qualified to do what they are doing without some help. I can see where the pharmacist combined with a nurse practitioner could be an extremely valuable asset to a patients care. But, NP’s alone are just not going to be able to fill the physician gap and provide quality care. I can forsee all kinds of possible uses for pharmacists, other than just dispensing. We have a big disadvantage when it comes to getting our foot in the door to doing things other than dispensing. As pharmacyslave2000 says, “These other healthcare workers (PA’s, NP’s, RN’s, etc.) function, in at least a small capacity, as autonomous professionals. They are allowed to prescribe meds., read charts, dictate care, without any additional training. They’re ready to go right out of the box.”. These other professionals will get the first chance at filling the physician vacuum. And, as pharmacyslave2000 says, “we are employees of corporations”. To move into another pharmacy environment and to expand our capabilities, we are going to have to get away from these chains. Where we stand today…the future looks pretty bleak. I have always seen a lot of potential for pharmacists. But, we have never been able to fit into the healthcare system. We have always been at the periphery.

  12. Goose  •  Jul 1, 2013 @11:48 am

    Just saw a study on LinkedIn that said if medications were used correctly, healthcare would save “many billions” of dollars per year.
    This will have to be a grassroots effort and may require us to put our money where our mouth is.
    David Stanley just did it. A guy in Lafayette, Indiana just did it. Independents will lead this and make a comeback.
    I’m going to talk to a couple of docs I know about it.
    If we all wait for somebody else to start it, well, somebody better start it.

  13. Goose  •  Jul 1, 2013 @11:56 am

    Keep in mind also that NP and PAs all work for somebody as employees so somebody else just thought all this “MinuteClinic” stuff up. They are employees just like we are. They have no control over their destiny. I still think we do.
    Let’s get after it. Start by getting the skills. Then bulid some relationships with some MDs. Then document outcomes and start marketing.

  14. Goose  •  Jul 1, 2013 @3:03 pm

    One thing that stands out to me is that Obamacare will reward providers with good outcomes. So, if you can show good outcomes, you will be okay.
    Gone are the days of preferred deals to certain providers bases on business deals, i.e. cash.
    Why do you think business hates Obamacare so much? The fluff is that providing healthcare for all their workers will cost them money. It will actually save them money in the long run. It’s been proven. They just don’t want to give up the side deals. That’s their main concern. Business hates not having an advantage.
    On a level playing field, performers get rewarded and pretenders don’t. That’s what they are afraid of.
    Don’t drink the Kool-aid on Obamacare. Read the pharmacy portion, it’s around 130 pages. Hell, it’s a lot better than what we have now.
    Health insurance is just like all other insurance, if everyone plays and is honest, it works. If some people use leverage and try to game the system it doesn’t.
    JP won’t be writing this blog forever, I would hope you are sensing his frustration. Get off your ass and do something.

  15. pharmacyslave2000  •  Jul 3, 2013 @3:10 pm

    The debate here is not whether we are capable of filling this provider role (we are with some additional training) but instead how are we going to become recognized as providers. As Broncofan7 stated, we first need to become recognized as providers then we would need to battle the insurance companies for reimbursements. I agree that this is going to be a LONG battle against the AMA and at the end of it all it may not amount to much anyway.
    ***
    Assuming we get “provider” status, the next order of business is untying yourself from the corporate noose. Does ANYONE want the additional burden of being a “provider” AND working for a corporate chain? You think it’s bad now, can you imagine the metrics they could develop for this? We would never see a dime of additional money from any of our “provider” duties but instead would be held MORE accountable and MORE liable while the corporation ran us even further into the ground.
    ***
    Finally while Obamacare may provide additional opportunities, it is all about reducing healthcare costs in the end. Do you honestly think they would add pharmacists, the most under-qualified healthcare “provider” to the payment list? We’ve already established that we would indeed need additional training for safe and effective prescribing authority. Why would the program make accommodations for us? The shortage of primary care providers could be, at least initially, filled by NP’s, PA’s and RN’s. This isn’t to say that we can’t be and won’t be primary care providers at some point, it just won’t be anytime soon.

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