Why shouldn't pharmacists be prescribers?

Their specialized training renders them qualified to dispense some drugs without a physician's say-so, thereby lightening doctors' loads.

By Kathleen Johnson and Shirley Svorny

October 22, 2007

Allow pharmacists to dispense certain drugs without a prescription from a physician? The Food and Drug Administration is inviting comment on just such a proposal. The idea is to add a new class of "behind the counter" drugs that consumers could buy after consultation with a pharmacist.

Other countries, including Britain, already use this system to dispense drugs that do not require sophisticated diagnosis and prescription.

In 2006, the FDA set the stage for such a system when it allowed pharmacists to sell emergency contraception in the United States to patients over 18 on a behind-the-counter basis.

Other medication proposed for this category include drugs for migraine headache and ones that improve cholesterol levels. This is the logical next step in a progression to reduce the cost and improve access to healthcare in this country.

This proposal would allow pharmacists to take on some tasks previously limited to physicians. Heavy lobbying by physician organizations at the federal and state levels has led to restrictive "scope-of-practice" rules that can't be justified on a clinical basis.

There are many situations in which pharmacists already safely counsel patients on appropriate drug use and the management of chronic diseases. In fact, laws in California and many other states allow pharmacists to initiate or change therapy in cooperation with physicians. These tasks are performed routinely by pharmacists in many organized healthcare settings, such as Kaiser Permanente, the Indian Health Service and the health system of the Department of Veterans Affairs.

Many physician group practices also hire pharmacists to manage patients with chronic diseases to improve quality of care.

A recent study found that pharmacists providing chronic-disease management substantially improve clinical measures of disease control for patients with diabetes.

However, restrictions on reimbursement to pharmacists for disease management in non-organized systems and pharmacies reduce the incentives and availability of pharmacists to provide these services.

Adding pharmacists to the list of individuals who may prescribe medicine independently makes sense. We have already taken some steps to liberalize prescriptive powers of so-called non-physician clinicians. To improve access to healthcare in underserved rural areas, many states passed laws to allow nurse practitioners (nurses with special training) and physician assistants to prescribe drugs in specified areas.

When the world did not end after those changes, some states continued to experiment with giving non-physician clinicians increased responsibilities. In more than a dozen states, nurse practitioners now have full authority to prescribe drugs (including controlled substances) independent of any physician oversight.

Studies suggest that nurse practitioners and physician assistants can take on many of the tasks (perhaps 80% of primary care tasks) previously set aside as physician-only tasks -- and safely. Researchers have not found worse outcomes, and in some cases, have found better outcomes under such care.

Pharmacists, with four years of postgraduate education followed by residency training in many cases, have substantially more training in pharmacology and therapeutics than nurse practitioners and physician assistants. For all practical purposes, the pharmacist is the medications expert on today's healthcare team.

Expanding responsibility for pharmacists, as proposed by the FDA, would lower the cost of healthcare. Costs fall when individuals take on specialized functions. In this case, by shifting some tasks to pharmacists, physicians are freed to focus on tasks that require more specialized skills (diagnosis, for example).

Despite what the American Medical Assn. and state medical associations will say, highly paid physicians don't need to be called on for every task. By moving certain drugs to the proposed behind-the-counter status, we can take one more step away from the restrictive rules that have limited the contributions of non-physician clinicians and hamstrung efforts to improve efficiency and access in the healthcare system.

Kathleen Johnson is a professor and chairwoman of the Titus Family Department of Clinical Pharmacy and Pharmaceutical Economics & Policy at USC. Shirley Svorny is a professor and chairwoman of the Department of Economics at Cal State Northridge.