Original Full Article: http://www.nclnet.org/koreaweb.htm
The prospect of increasing numbers of physicians routinely dispensing drugs for profit has captured the attention of pharmacy, consumer, and medical groups as well as the state and federal governments. Heated debate about the practice is being waged at both the state and national government levels over the complex variety of ethical, economic, public health, and regulatory issues related to the practice. Is it a conflict of interest for doctors to sell the prescription drugs they prescribe? Is the quality of patient care enhanced or harmed by physician dispensing? Does the practice promote or restrain competition? What kind of regulation, if any, should be put into place, and at what level--state-by-state or a federal code? Finally, is the practice good or bad for the consumer? These are the main questions that must be asked and addressed.
Of course, there are already many differing opinions from both sides of this issue. The argument is usually framed as an adversarial one with physicians on one side and pharmacists on the other, and both sides claiming that they have the patients' best interests in mind. Those in favor of physician dispensing make several claims as to why they should dispense prescription drugs:
On the other side of the issue, pharmacists have several claims as to why there should be a separation between the prescribing and dispensing:
Nearly all states have some type of regulation governing the dispensing of drugs by physicians. 43 states allow physicians to dispense pharmaceuticals to their own patients without regard to quantity. Only six states place some sort of restriction on physician dispensing (Texas, Virginia, Utah, Arizona, New Hampshire, Massachusetts). There are five major types of regulatory requirements:
These state regulation requirements are much less extensive than those regulating pharmacists and have minimal impact on physician practices. At the federal level, the Federal Trade Commission (FTC) endorses physician dispensing, claiming that it "increases service and price competition among practitioners, and between practitioners and pharmacists, to the benefit of consumers."The Federal Trade Commission is mostly concerned with increasing competition and consumer choice and costs. On this issue, they have not dealt with the issues of safety, ethics, and conflicts of interest, much to the dismay of pharmacists and others who oppose the practice.
Now that I have addressed what the doctors, pharmacists, and government regulators think, let's look at how the consumer feels about the issue. According to the results of a consumer survey done by the Roper organization, the American consumer prefers to buy prescription drugs in a pharmacy rather than at a doctor's office by nearly a 4 to 1 margin. 61 percent would prefer to buy their prescription drugs at a pharmacy, compared to only 16 percent who would prefer to buy them at a physician's office. By a 3 to 1 margin, consumers believe that there is a conflict of interest when a physician prescribes and sells these drugs to patients (62 % to 21%). Furthermore, 52 percent believe that a pharmacist is more knowledgeable than a physician regarding prescription drugs. In older patients, the percentage is even greater--68 percent.
While there seems to be a growing movement to physician dispensing of prescription drugs, with most state and the federal government's approval, consumers are hesitant to embrace this new trend.
Now that we have explored physician dispensing of prescription drugs, let us explore the other side of the issue--pharmacists prescribing prescription drugs. Pharmacists have increasing opportunities to initiate or modify drug therapy--functions that will help support their growing roles as managers of patients' drug therapy. Eleven states have given pharmacists the authority to administer and initiate or modify drug therapy, usually working with physicians under established guidelines.
In addition, in March 1995 the Veterans Health Administration of the U.S. Department of Veterans Affairs (VA) issued a directive that allows appropriately trained pharmacists to prescribe medications within the scope of their practices. The policy was developed to provide consistency and maximum practice flexibility within the 171 Veterans Affairs Medical Centers. The policy signals a potentially larger role for pharmacists in managed care and health management. Many pharmacists feel that their role must expand if they are to function effectively in a managed care environment.
The majority of states that allow this practice require pharmacists to undergo additional clinical training or have extensive clinical experience. Pharmacists must follow specific guidelines or protocols that have been established. Currently, the majority of pharmacists who do prescribe are in clinical or institutional settings--hospitals, health clinics, and managed care organizations. Independent pharmacists have not embraced the practice quite yet. However, several states have recently expanded authority for pharmacist prescribing, most notably, California, New Mexico, and Nevada. Florida is the only state that allows pharmacists prescriptive authority independent from physician supervision, but the authority is restricted to a formulary of fewer than 50 drugs. They are seeking to expand this formulary, which would require additional training for pharmacists, but the expansion is still in discussion in the legislature.
With pharmacist prescriptive authority, many of the same issues and questions arise that are raised in the discussion over physician dispensing of drugs. First of all, pharmacists are divided over the issue, with many agreeing that most do not have adequate diagnostic and physical assessment training and are uncertain about what they can and cannot do. Some are unwilling to take on the added risk and responsibility. Community pharmacists are especially unlikely to become prescribers because they practice in isolated settings, often without access to patient records and medical data. Fewer than 1,000 pharmacy school graduates are trained well enough to prescribe medications.
Ethical problems and conflict-of-interest issues also arise. Just as physician dispensing disrupts the system of checks and balances between prescribing and dispensing, so too does pharmacist prescribing. The problem of over prescribing or prescribing certain drugs to make a profit is also something that has to be considered. Despite these problems, there have been several studies that show pharmacists add value to patient care when they practice pharmaceutical care.
Studies conducted in California, Texas, and Washington showed that pharmacist's care resulted in improved outcomes. Researchers found other benefits as well. Pharmacists could monitor patient drug therapy more intensively, increase patient satisfaction and convenience, and decrease the cost of patient care. Pharmacists can be more focused than physicians on compliance and patient education, areas that have a significant impact on patient outcomes and health care costs.
With the country moving toward managed care, more pharmacists will be in arenas where they may be granted the opportunities to prescribe, providing new career opportunities for them, and possibly better health and cost outcomes for the consumer.
Original Full Article: http://www.nclnet.org/koreaweb.htm