On January 1, 2014, a bill signed by Governor Jerry Brown fundamentally transformed how pharmacists operate in California.
The new law allows pharmacists in the most populous state in the nation to independently prescribe vaccinations, hormonal contraception, smoking cessation medications, and travel medicine without physician oversight or supervision. Importantly, the bill declares that “pharmacists are healthcare providers who have the authority to provide healthcare services,” which may include preventative and chronic medical care normally only available from licensed physicians.
With physician reimbursements declining, healthcare costs rising, and more patients preferring ease of access to the classic experience of visiting a physician, I sat down with Marilyn Stebbins, a clinical pharmacist and Vice Chair of Clinical Innovation at the University of California San Francisco, who sees it as “the perfect storm of a primary care shortage.”
Currently, CVS Caremark’s nearly 600 Minute Clinics and Walgreen’s 350 Take Care clinics rely on a combination of medical practitioners to deliver seasonal or episodic care such as flu vaccines, cold remedies, or decongestants independent of the primary care team. However, the cost structure associated with having a nurse, a midlevel practitioner, and a pharmacist deliver a limited scope of offerings has turned these clinics into marketing operations. The majority of outlets offer the services simply to attract more customers to the retail aisles, and to capture their prescription-medication purchases.
Also limiting expansion has been a lack of enthusiasm from healthcare networks, insurance companies, and primary care physicians due to the dangers of treating patients in isolation. For example, over the past year alone, there have been multiple reports on the hazards of retail health. Herbal supplements have caused fatal medication interactions while some elderly patients have suffered unneeded complications after receiving multiple doses of the shingles and flu vaccines (which are attenuated but live) from varying retail clinics.
Clearly, as pharmacists in California begin providing chronic medical management in addition to seasonal, ancillary, and acute symptomatic management, there will be a heightened level of scrutiny. The medications involved in chronic condition management, while typically quite safe individually, can be dangerous when combined in the treatment of a single patient. Given that the average American fills 12 prescriptions each year, the potential for serious adverse interactions is real.
“Creating an accurate patient-centered medication list is fundamental to the health of the patient,” agrees Stebbins. UCSF’s response: open a flagship Walgreens Pharmacy directly on its main medical campus.
“It will look and feel like an Apple Store,” Stebbins explains. “No products will be in plain sight. Instead, pharmacists will meet and greet each patient upfront.” With access to UCSF’s electronic medical record, pharmacists will be able document, record, and provide medications as prescribed by the primary care physician from an up-to-date medication list.
“Right now, pharmacists operate in silos,” concludes Stebbins, “and that has to change” in order to keep patients safe and reduce healthcare costs.
Barriers, however, remain. Walgreens’ and UCSF’s differing health records have so far prevented any meaningful cross-platform data integration, requiring information to be entered into both in a duplicative manner. Furthermore, there is no definitive plan to address the large portion of patients who visit academic centers such as UCSF, but rely on a primary care team that lies outside of the tertiary care network. Given that no integration of UCSF’s and Walgreens’ networks is planned at this time, its true effectiveness may be limited when patients return home.
While Walgreens is taking a major leap forward by creating an integrated partnership with UCSF, it’s Walmart, with its nearly 11,000 retail outlets, that actually has the greatest opportunity to capitalize on these legislative changes. It has not only
