Pharmacists’ Scope of Practice… Future Directions & Strategies

1. Pharmacists’ Scope of Practice… Future Directions & Strategies “Ground-Level View; What’s Happening in the States?” • Jeff Rochon, Washington State Pharmacy Association • Aliyah Horton, Maryland Pharmacists Association

2. Washington State’s Discussions on Diagnosis, Scope and Collaboration Jeff Rochon, Pharm.D., FAPhA Chief Executive Officer Washington State Pharmacy Association

3. Achieving Patient Access Patient Access to Pharmacists’ Patient Care Services

4. Provider Designation Provider Designation Optimization of Pharmacy Practice Act • Pharmacists are healthcare providers in Washington State Law • Incorporated in appropriate practitioner and healthcare provider definitions • Review of statutes and rules • Took multiple efforts over the years Payment for Service

5. Provider Designation Scope of Practice Optimization of Pharmacy Practice Act • 1979 • Definition of Pharmacy Practice “Practice Act” • RCW 18.64.011 includes: • “initiating and modifying drug therapy through written protocols and guidelines” • “administering” of drugs and devices • “monitoring of drug therapy and use” • ordering and interpreting labs Payment for Service

6. Collaborative Practice in Washington Public Health • Immunizations • Emergency Contraception • Tobacco Cessation • Emergency Prep Antiviral • Opioid Overdose Prevention • Contraception • Tuberculosis Screening • Travel Medications • Pre-Exposure Prophylaxis Chronic Disease • Anticoagulation • Dyslipidemia • Diabetes • Hypertension • Asthma • Pain • Heart Failure • Oncology • Comprehensive Med Reviews **Currently, over 33,000 active CPA’s on file with Pharmacy Quality Assurance Commission

7. Independent vs collaborative prescribing • Medical Community opposes expansion of independent Prescriptive authority • Legislature prefers to avoid turf battles • Health plans don’t pay providers to prescribe • Team-based care is embraced • Collaborative relationships could be valuable

8. Still Lacked Recognition by Payers Patient Access to Pharmacists’ Patient Care Services

9. WASHINGTON STATE’S AG REQUEST BY MEDICAL COMMISSION • June 6, 2018 • Washington State Medical Commission (WMC) Chair submits request for Attorney General opinion on six questions

10. WMC Concern • “Absent from both the statute and the rule is any reference to whether a pharmacist may diagnose or assess a patient's ailment. However, the commission recently learned that the Washington State Pharmacy Association (WSPA) developed a program for patient care entitled the “Clinical Community Pharmacist (CCP)" that allows pharmacists to prescribe therapies for patients in acute situations to reduce urgent care and emergency room visits.”

11. WMC Concern • ‘This training provides a "comprehensive review of a disease state, the differential diagnosis to rule out other causes of symptoms, and treatment recommendations." These reviews last between 30 to 90 minutes. Once a pharmacist has completed this training, they receive a clinical pharmacist certificate.’

12. WMC Concern • ‘Under one particular CDTA program by a pharmacy chain, CCPs can assess and prescribe treatment for these disease states. In their CCP protocol, this pharmacy chain lists "diagnosis" as one of the steps the CCP takes.’ • ‘For example, for insect stings they require the CCP to use a patient questionnaire, pharmacist evaluation form, a one-on-one consultation with the patient, and evaluation of the sting to decide appropriate treatment and/or referral. • Another CDTA program run by a different pharmacy chain relies on a diagnostic "treatment algorithm“ for the pharmacist to decide on the appropriate treatment for possible urinary tract infections.’

13. Six Questions 1. Does the phrase "the initiating or modifying of drug therapy in accordance with written guidelines or protocols previously established and approved for his or her practice by a practitioner authorized to prescribe drugs" include the act of diagnosing a patient's condition? 2. If the answer to # I above is yes, is there a statutory or administrative requirement for direct contact between the non-pharmacist practitioner and the patient?

14. Questions continued 3. May a physician licensed under RCW 18.71 delegate the diagnosis of a patient to a pharmacist licensed under RCW 18.64? 4. Does a pharmacist who diagnoses patients pursuant to a CDTA with a physician commit an act of unlicensed practice of medicine under RCW 18.130.190?

15. Questions continued 5. May a physician assistant licensed under RCW I8.71A delegate the diagnosis of a patient to a pharmacist licensed under RCW 18.64? 6. Does a pharmacist who diagnoses patients pursuant to a CDTA with a physician assistant commit an act of unlicensed practice as a physician assistant under RCW 18.130.190?

16. Key Points • AG opinions are based on statutory language • Questioning statute that has been in existence since 1979 • Medical Commission is not Medical Association

17. ACtion • Focused on Pharmacy Quality Assurance Commission’s Response • Met with PQAC And WMC • Met with WSMA • Met with Key Legislators • Discussed with National Leaders • Provided Comments on behalf of WSPA

18. Expected Formal Opinion • Aag for PQAC is primary contact • Anticipated aN AG formal opinion December 2018 • Aag assigned to the opinion won election • Opinion reassigned • New aag starts the process over • Opinion Anticipated in 2019

19. Questions? Jeff Rochon, Pharm.D., FAPhA Chief Executive Officer Washington State Pharmacy Association jeff@wsparx.org

20. Pharmacist’s Scope Expansion: Feels like an Infinity War Aliyah N. Horton, CAE Executive Director Maryland Pharmacists Association

21. It’s a Battle

22. Context • BAD GUY– Wants to rule the world and determine how it is led. Has to keep components (infinity stones) to fulfill that goal • GOOD GUYS – Potentially everyoneelse, fighting for each stone • to ensure the best outcomes • but there’s infighting and politics

23. Scope Expansion – Everybody wants it

24. Strong legislative champions Prescriber/provider support Political wind Data (access and safety) National org. support Success • Contraceptive Prescribing

25. Round Two • Tobacco Cessation Prescribing • Medication Administration – Long Acting Injectables

26. Challenges • Mixed Responses from Allies • Lack of Uniformity in Support • Politics • Practice vs. Operations • Hyperbole as fact • Perception of Self-serving

27. Teamwork JCPP • DATA DATA DATA • Information in support or opposition • Highlight where state entities may be diverging from national org. policy • Statements from national provider organizations/patient advocacy groups • Recommendations from HHS or CMS

28. Improved Patient Access and Outcomes can be Achieved

29. Questions? • Aliyah N. Horton, CAE • Executive Director • Aliyah.Horton@mdpha.com • Facebook: /MarylandPharmacistsAssociation • Twitter: @MDPharmacists • Instagram: MDpharmacist • Website: www.marylandpharmacist.org

30. Pharmacists’ Scope of Practice… Future Directions & Strategies Questions? “Ground-Level View; What’s Happening in the States?” • Jeff Rochon, Washington State Pharmacy Association • Aliyah Horton, Maryland Pharmacists Association