28 August 2013

Pharmacists' Role in Primary Care to Expand

Medical doctors may not be seeing what is happening and soon it will be too late for any action. More states, and especially states with large urban centers and large areas of rural populations that are very doctor sparse, are considering legal actions to confront this doctor shift and in some areas extreme primary care physician shortages.

Recently, the federal government has experimented with success using pharmacists in the delivery of healthcare on the Indian reservations. This project involved diabetes education and the ability to prescribe drugs. This program is probably an introduction of a federal push for greater pharmacist participation in the overall national health system.

California is loosening up their restrictions and they have to. Many doctors are leaving the state's inland rural areas. These areas are beginning to suffer from a physician shortage as primary care doctors migrate to California's wealthier coastal enclaves to generate incomes large enough to offset their medical training debt. Then the California Medical Association said the state could alleviate the looming physician shortage by building additional medical schools, adding medical residency slots, and expanding programs to help physicians pay off student loans in exchange for working in underserved communities.

This is laughable because a big problem for the state is that it lacks the money to build more schools or help medical school graduates pay off their student debt. California's bonding capacity has been downgraded over the past three years from AAA to A, which means the state must pay higher interest rates to attract bond buyers. The state has been flirting with insolvency for several years.

The California State Senate passed SB 493, which is a bill that would give pharmacists broader scope as healthcare providers. This joins SB 491 and SB 492 that expand the role of nurse practitioners and optometrists, respectively in the State Assembly's Business and Professions Committee. This is the latest on this.

In Tennessee, an experiment carried out by the Diabetes Initiative Program followed 206 adult type 2 patients for a year to see if intense collaboration between physicians and pharmacists could lead to a reduction in patient's A1c's. Here pharmacists provided education, ordered lab tests, made referrals, and helped manage drug therapy, including discontinuing it if they thought it appropriate. The study noted an increase in the number of patients whose A1c's were below 7%, from almost 13 percent of participants to nearly 37 percent, and concluded that the doctor/pharmacist collaboration helped produce that outcome.

Generally speaking, pharmacists are more accessible to patients than their primary care physicians. Those relationships are more informal, rarely dependent on appointments, and often involve more frequent contacts. Greater patient comfort with pharmacists translates into a greater likelihood that they will follow pharmacists' advice and recommendations. Giving pharmacists increased legal authority to deliver certain aspects of primary care would have the advantage of building on an already established set of solid relationships.”

A study from the George Washington School of Public Health and Health Services found that the United States is producing an alarmingly low number of primary care physicians. According to the study, less than 25 percent of newly credentialed doctors go into primary care medicine, and of that number, only 4.8 percent set up practices in rural areas. This shortage sets the stage for including pharmacists, nurse practitioners, and other healthcare providers to help fill the primary care provider gap.

California's problems serving rural areas with an adequate number of primary care physicians turns out to be a nationwide concern. Along with the conclusions stated in the George Washington University study, there is an increasing likelihood that as the Affordable Care Act comes more into play, it will have two negative impacts on the number of physicians-one absolute and one relative:

#1. Medicine will become an increasingly unattractive field as profit margins are squeezed by regulations. This in conjunction with the rising cost of a medical education, which, like all student tuition costs, has been rising for years far faster than the rate of inflation. Net result: fewer young people entering the medical profession.

#2. Doctors who do not wish to be forced into group practices dependent on government regulation and reimbursements will form independent "concierge" practices where patients pay a set yearly fee, usually in the thousands of dollars, for non insurance-dependent healthcare. These practices work best in densely populated, relatively affluent areas. Net result: fewer doctors among those currently available to practice among patients who either cannot afford non-insured services or live far from urban centers.”

Where will this leave many patients? Without states making it possible for pharmacists, nurse practitioners, and other healthcare providers to practice primary care, the voters may have to insist on this at the federal and state levels.

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