Pharmacists (Position Paper)

The Academy recognizes the evolving complexity and proliferation of pharmaceutical agents and the important role of pharmacists participating in the provision of high quality health care. The pharmacy professional and physician can and should work in a collaborative environment where their combined expertise is used to optimize the therapeutic effect of pharmaceutical agents in patient care. It is the intent of this document to define the nature of that relationship.

The pharmaceutical armamentarium is one of the most rapidly evolving elements of the clinical continuum. The pharmaceutical industry has produced in recent years a large number of effective medications with an ever-expanding range of applications. Additionally, the industry has greatly impacted both patients and physicians by their decision to market directly to the public. Illustrative of the dynamics compounding the complexity is that many of the largest selling drugs in the country have, or will soon lose patent protection. Patients are already being pressured to switch to generic medications as insurance companies attempt to regain some control over pharmaceutical costs. Pharmaceutical costs as a percent of total costs for a typical managed care plan has increased 85% in the past decade.¹ While the Academy is aware of the need and supports initiatives to reduce health care costs, pressure to reduce costs should not take precedence over patient needs.

The increased complexity of pharmaceutical applications is at least partially reflected in the profession's decision to upgrade its educational standards. Until July 1, 2000, an individual who wished to become a pharmacist could enroll in a program of study that would lead to either a Bachelor of Science degree or a Doctor of Pharmacy degree. As of July 1, 2000, the doctor of pharmacy became the only degree accredited by the American Council on Pharmaceutical Education (ACPE). Pharm. D. programs take six years to complete and usually involve two years of preprofessional coursework and four years of professional education.² For the purposes of this document the terms pharmacist(s), Pharm. D., and pharmacy professional are interchangeable.

Pharmacists, like other health professionals, are seeking to expand their influence and scope of practice. This is consistent with the overall expansion in the level of medical complexity and mirrors the subspecialization of other medical professions.

Expanded roles for pharmacists have legislative and regulatory support. Currently, 32 states have collaborative drug therapy management (CDTM) legislation or regulations.³ These laws allow physicians and pharmacists to enter into voluntary written agreements to manage the drug therapy of a patient or group of patients. Forty states have legislation requiring insurance plans to cover self-management education for patients with diabetes and some of these states list pharmacists among the health professionals who may provide and receive payment for diabetes education and self management services.³ Pharmacists have the authority to immunize patients in 32 states.³ The significance of the pharmacy professional is even greater since an estimated 250 million people walk into a pharmacy every week.⁴ Pharmacists may represent the most accessible professional in the health care system.⁴

It would be within the parameters established by current policy that the issues of pharmacy professionals taking an independent role in medical management situations or managing medications in disease state management (DSM) programs would be defined. The Academy's policy, Disease State Management, specifically lists outpatient drug management as a component present in most effective disease state management programs.⁵ A report from the University of Arizona Center for Pharmaceutical Economics states that the annual costs of medication-related mortality and morbidity is $76.6 billion with a potential reduction of $45.6 billion through the application of pharmaceutical care services.⁶ Where disease state management programs have been developed to address specific high-cost and/or high volume diagnosis, and when such programs have a pharmaceutical element that is an essential element of the overall program, there is a critically important role for the pharmacist.

Pharmacists have an important role in providing direction to patients seeking advice on over-the-counter medications. Even if desirable, it is not practical to assume that a physician will be consulted in most instances where nonprescribed medication is involved. In the absence of direction from a physician and in instances where a patient is seeking information, the pharmacy professional is the logical source to provide that information. For the patient seeking nonprescription medication, the pharmacist is positioned to determine the presence of allergies, as well as additional medications being taken which could adversely react with the over-the-counter medicine.

With increased emphasis on the use of prescription medication, the expanding role of the pharmacy professional directly affects family physicians. In a collaborative environment the pharmacist is a logical member of a team and qualified to deal with issues of drug usage, medication efficacy, and medication use patterns.

As indicated, 32 states allow physicians and pharmacists to enter into voluntary written arrangements to manage the drug therapy of patients. The Academy's policy on Integrated Practice Arrangements states, however, while the Academy supports health professionals working together, "…interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician."⁵ The policy defines the central issue of positioning the family physician as "coordinator" and defining the pharmacy professional. As stated previously, Academy policy clearly states that in all instances supervision by a physician is a paramount concern.

The expansion of the pharmacist's professional role has made certain aspects of current Academy policy on non-physician providers (NPPs) applicable. The policy states that, "The central principle underlying physician supervision of NPPs is that the physician retains ultimate responsibility for the patient care rendered. Physician supervision means that the NPP only performs medical acts and procedures that have been specifically authorized and directed by the supervising physician (emphasis added)."⁵ This aspect of the policy would certainly be applicable in those instances where a collaborative (or integrated) approach is being utilized to optimize drug therapy.

At issue is the nature of the appropriate relationship between family physicians and pharmacy professionals. Although evolving, the basic aspect of the relationship is the fact that the pharmacist dispenses the medication prescribed by the physician or the physician's designated surrogate who is under the appropriate level of supervision by the physician.

After an examination and determination of what is in the best interests of the patient the family physician is best positioned to prescribe medications. As indicated by the Academy's recently revised policy, Drugs, Prescribing, " The AAFP believes that only licensed doctors of medicine, osteopathy, dentistry, and podiatry should have the statutory authority to prescribe drugs…"⁵ The pharmacy professional is in the position to dispense the prescription written by the physician.

Given the ever-expanding number and complexity of pharmaceutical agents, family physicians' relationship with pharmacists is not dissimilar to that with specialist and subspecialist physicians. Obviously the level of autonomy accorded other specialist physicians is not appropriate when dealing with pharmacy professionals, but in terms of acknowledging and utilizing expertise the process is similar.

There is a growing body of research indicating that physicians and pharmacy professionals working in a collaborative environment can make positive contributions to patient health. Certain areas have been identified which seem amenable to the presence of a pharmacy professional. Patients treated in a pharmacist-managed clinic had better anticoagulation control, fewer bleeding and thrombotic complications, fewer hospitalizations and emergency room visits, and lower health care costs compared to newly anticoagulated patients treated in the standard manner.⁷ Collaborative programs have demonstrated success in other areas, including hyperlipidemia, asthma, diabetes, and hypertension.⁸ The program basics are similar in each instance. Pharmacist participation entails monitoring compliance, reviewing drug therapy, recommending changes in drug regimens, and education in behavior modification.

The Academy recognizes the unique expertise of the pharmacist. Because of this expertise there are areas of professional activity where by law the pharmacist practices independently and other areas where that expertise is best exercised in an environment with physician supervision. While pharmacy professionals should not prescribe drugs or alter in any manner a prescription written by a physician, they have valuable contributions to make in a team environment with a strong pharmaceutical component.

(2002) (August 2006)