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.

Key to Medication Adherence Is Education

This is very interesting, one group saying medication education is the key to adherence and another group saying that limited literacy may reduce medication adherence. Both are saying basically the same thing.

One group is calling for education as a tool for patients to understand their medications and how they help the condition for which they are prescribed. But will this work in the real world, that is the big question. Yes, the Skaggs School of Pharmacy and Pharmacotherapy at the University of California, San Diego says that pharmacists and other health care providers need to assess the patient and include this education as part of their services.

The other study describes the problem of how the way physicians write the prescription and the pharmacist puts the instructions in the package for the patient. The two can often conflict and the patient is left wondering whether the doctor or the pharmacist is correct. They are calling for standardization of the prescription instructions.

Between the two studies, it appears that education needs to begin with the doctor and proceed to the pharmacist and then to the patient. This will require the manufacture to provide an update to the doctors of prescription requirements and possibly allowing the doctor the opportunity to print the prescription instructions for the patient. Most of this would be using standardized formats and then the pharmacist would be able to do the education of the patient. Actually a little education could be done by the doctor, but the bulk of the education would be by the pharmacist since they should be aware of all medications and where conflicts might arise.

In either study, it should be noted that education can be the key to adherence and this should be the emphasis. Read about the study at the University of California, San Diego here. Then read the other study at the University in Chicago, Illinois here. This should be a wake up about the problems that can arise.

Another Reason for Talking to Your Doctor

There is a growing epidemic in this country and it is on two fronts. Many people are not talking to their doctors. And at the same time doctors are not talking to their patients. These are not what I am referring to, but are part of the epidemic.

Medical situations arise every day and people think they can handle them without talking to their doctor. A brief article the other day made a excellent point about the need to talk to your doctor. Some people will disagree with what I am going to say, but they are the ones that will end up in the emergency room and the hospital or even the local mortuary. Yes, it is that serious.

When people come down with the common cold or also develop problems with mucus plugging their nose, they head for the nearest store or pharmacy to get a decongestant. If you are healthy and have no known medical problems, chances are that no damage will be done.

But if you have any of the following health conditions, doing this is not advisable. These health conditions are heart problems or high blood pressure, glaucoma, thyroid problems, diabetes, or prostrate problems. With these conditions, it is wise to consult with your doctor. Most over-the-counter products like decongestants are clearly labeled with a warning for high blood pressure but little else. Some do say they will raise blood glucose levels.

Most people will demand privacy and other grounds for avoiding what I am proposing, but after seeing a friend in the hospital last week for just the above situation, I think for the sake of safety, all over-the-counter drugs that require a warning, should only be available through a pharmacy and be kept behind the counter requiring either a prescription if they have health problems or must be handed out by the pharmacist.

This may be an unnecessary burden on doctors and pharmacists, but in this day with computers, this should be workable. Some patients will go to extreme measures to avoid this happening and shop pharmacies to avoid the need for a prescription. They will do anything to step around the system. The dangers of doing this are there and people still want to ignore them.

This is the reason that I only have two pharmacies and and all my doctors know which ones to deal with. If I am looking for an over-the-counter medicine, I talk with the pharmacist after I have read the label. Often the pharmacist suggests another product that does not have the dangers. Occasionally I am told to not take any and go to the doctor. I respect the pharmacist for this and this is one reason you do not want many pharmacists to deal with.

I find that these relationships work for my better health care and as a result, the doctors are more confident in what I do. Plus the pharmacist is more willing to answer questions and even supplies me with additional information when it is felt that it will be of value.

Read the very brief article here.