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Advanced practice pharmacists are ready
By Grant Burningham / Thu Nov 9, 2017
Like many rural areas, Kern County, California, has a shortage of doctors. Kern County also has a teen pregnancy rate nearly twice the national average and a sexually transmitted disease infection rate 46 percent higher than the rest of the state.
The shortage is a chance for UCSF School of Pharmacy alumnus Brian K. Komoto, PharmD ’81, to serve the community—and to have his profession fill the gap. Komoto owns three pharmacies in Delano in Kern County, and his pharmacists have been at the forefront of adopting new powers given to them by recent changes in California law.
In 2013, California Governor Jerry Brown signed the “pharmacy practice bill,” Senate Bill 493, which stated that “pharmacists are health care providers who have the authority to provide health care services.”
The bill gave all California pharmacists the authority to:
- “Furnish”—the law’s language for prescribing—hormonal contraception
- Provide smoking cessation services, including nicotine therapy medications
- Provide travel medications
- Order tests to monitor efficacy and toxicity of a patient’s medication regimens
These authorities require their own certifications and approvals, and pharmacists need to work in concert with primary care doctors.
The bill also created a new pharmacist license, called the advanced practice pharmacist (APh), that allows certified professionals to initiate, adjust, and discontinue drug therapy.
“We need to be recognized as providers at the state and national levels.” –Brian Komoto, PharmD ’81
The changes are part of a national movement empowering pharmacists to work at the “top of their licenses.” California has followed Oregon and Washington, which already have the expanded roles.
Another bill, AB 1535, gave pharmacists the ability to prescribe naloxone, an opioid overdose treatment.
Komoto says the laws are part of a trend: “Pharmacists are going to be more integral to the health care team in the future. We need to be recognized as providers at the state and national levels.”
So far this year, the California State Board of Pharmacy has licensed 140 APh professionals. Komoto has hired two APh pharmacists and has two staff pharmacists who are going through the certification process now.
For Komoto, the APh means that his pharmacists can help the community by taking on more health care responsibilities. One of his APh pharmacists runs a pharmacist clinic in a physician group. That would have been allowed before, under a joint-operating agreement with a doctor, but now the pharmacist can work with patients directly. Komoto is even working with the school district to run a pilot program that would allow his pharmacists to go to public school clinics, where they could treat sexually transmitted diseases (STDs).
That’s the good news. The bad news is that pharmacists face some implementation hurdles when it comes to their expanded scope of practice—mostly notably, getting paid for the new services they provide.
Expanding care roles require new payment models
SB 493 was passed without any provision for how pharmacists would bill insurance providers—including Medicare or Medicaid—for their work, leaving only cash payments. California's AB 1114, which passed last year, allowed pharmacists to bill Medi-Cal, the state’s Medicaid system. It’s likely that insurance companies will follow suit and open payments as well. But that law, passed as an “urgency bill,” is still in the implementation stage.
In Kern County, the Medi-Cal managed care plan covers more than half of the population, and Komoto has worked directly with the plan administrators to implement billing.
Two federal bills, HR 592 and Senate 109, could speed a payment fix by allowing pharmacists to bill for any service their state’s laws allow them to perform. The proposed laws are primarily aimed at underserved counties, but their loose definition of “rural” would mean that 51 of 58 counties in California alone would qualify under the law.
Because of their accessibility, expanding the role of pharmacists seems like an obvious way of easing physician shortages and helping underserved communities. And pharmacists’ skills are often underutilized, even as the health care system as a whole is increasingly overstretched. But many UCSF pharmacy graduates already do many of jobs laid out in the bill, under collaborative practice agreements with physicians.
“Pharmacists are often touted as one of the most-accessible health care professionals,” says Lisa Kroon, PharmD, chair of the UCSF School of Pharmacy’s Department of Clinical Pharmacy. “Patients with chronic conditions can go months to years without seeing their physician, but they could see their pharmacist every time they fill a prescription,” she notes. Kroon worked on the committee to implement SB 493.
Beyond being able to “furnish” certain medications (SB 493’s language for prescribing) the bill allows pharmacists to order tests. According to Kroon, that could mean ordering an A1C test for patients with diabetes, to assess their long-term blood glucose control and to ensure that their diabetes medication is still at the right dose, or checking patients’ electrolyte levels on certain blood pressure drugs.
Pharmacists are ready; changes will follow
If pharmacists are ready to serve and the law is ready to let them, the problem continues to be billing, according to Marilyn Stebbins, PharmD, UCSF School of Pharmacy faculty member and vice chair of clinical innovation in the School’s Department of Clinical Pharmacy. The national bills have bipartisan support and could pass any day, but Stebbins warns that other structural changes will need to follow. “Pharmacies will have to retool to provide the services," she says.
All this may seem like a long, tortuous path to what is a solid, commonsense change, but Stebbins says that, given the complexity of the health system and of payment models, it’s to be expected. It turns out that when it comes to medical legislation, the road from bill to law is only the first step. "You get the authority, but you don't get the money with it,” she says. Now you get the money, but you have to build the reimbursement systems. So it's a long process.”
The expanding role for pharmacists as health care providers is coming, even if it’s taking time for bureaucracies to catch up. "Pharmacists need to get paid for the care they provide, and they've got to be able to bill,” Stebbins says. "If the money part is fixed, pharmacies will have to find ways to deliver on these new clinical services. There will be no more excuses."
New standard of practice and care
In the meantime, UCSF’s PharmD program is creating an expectation that students will take the next steps toward the certification for the new authorities and for licensure as an advanced practice pharmacist.
To receive the APh license in California, candidates must have two of three requirements: a postgraduate residency, one year practicing under a collaborative practice agreement, and/or a practice-based certification in a relevant area of practice.
As of last year, 67 percent of UCSF PharmD graduates go on to complete a residency and many go on to work in collaborative practice agreements, according to Kroon. “We already prepare our students—now the law better reflects that they can do that work,” she says.
As Kroon told Pharmacy Today, “There was a time when getting a flu shot at a pharmacy was novel. Now, this is a standard of care.”
Komoto sees the changes as portending a new outlook for the profession. “As much as there’s a concern about the number of pharmacy schools, there’s also a bigger future for pharmacists,” he says. “The profession is really transitioning. A few decades ago, we were talking about clinical pharmacy. Now we’re talking about how to directly serve patients.”
About the School: The UCSF School of Pharmacy is a premier graduate-level academic organization dedicated to improving health through precise therapeutics. It succeeds through innovative research, by educating PharmD health professional and PhD science students, and by caring for the therapeutics needs of patients while exploring innovative new models of patient care. The School was founded in 1872 as the first pharmacy school in the American West. It is an integral part of UC San Francisco, a leading university dedicated to promoting health worldwide.