Updated June 04, 2004
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JANE SPENCER, The Wall Street Journal
Tuesday, June 1, 2004
(06-01) 07:22 PDT (AP) --
When Debra Evans needed vaccines for a trip to
Ecuador, she didn't call her doctor. Instead, she
stopped by her local drugstore.
There, in an examining room not far from the
toothpaste aisle, her Seattle pharmacist gave her
shots for yellow fever and hepatitis A -- and also
wrote prescriptions for a handful of travel drugs,
including malaria pills and Cipro. "If I don't have to
go to the doctor, that's fine with me," she says.
Scribbling out prescriptions was once a task reserved
for doctors with years of specialized training. But a
growing number of states are allowing health-care
providers with less medical education -- including
pharmacists, certified midwives, and naturopaths -- to
prescribe drugs to patients.
The shift is occurring as state lawmakers look for
ways to cut health-care costs and make it easier for
people to get routine medications such as vaccines or
birth control. The new laws are often supported by
insurance companies, which stand to save money since
they can reimburse nondoctors at lower rates. In some
cases, major drug makers are also lobbying for new
rules, although the industry is divided on the issue.
The rapid spread of prescribing power is raising
concerns about medication safety, and generating
fierce opposition from physicians' groups, who say
that underqualified health-care providers are treading
on their professional turf.
While some nondoctors with substantial medical
training -- including nurse practitioners and
physician assistants -- have long been able to
prescribe in most states, the list of professions
seeking their own prescription pads is growing. Last
fall, California became the latest state to allow
naturopaths, who specialize in herbal remedies, to
prescribe some regular pharmaceuticals. Naturopaths in
Arizona and Hawaii can already write some
prescriptions. And lawmakers in Alaska recently
established a task force to evaluate a similar
proposal.
In February, Washington state launched a pilot program
that lets pharmacists prescribe birth-control pills
and patches to women. Like a handful of other states,
Washington already allows pharmacists to administer
vaccinations and dispense prescription
smoking-cessation products if they set up a special
agreement with a doctor.
This year, eight state legislatures dealt with bills
that would let women get prescription emergency
contraception, known as the morning-after pill,
directly from a pharmacist -- without seeing a doctor.
The future of many of the proposals hasn't been
determined, but this year Maine became the sixth state
to let pharmacists give the prescription drug to
patients who haven't seen a doctor.
In one of the longest-running battles over prescribing
authority, Louisiana's governor signed a bill last
month that will allow psychologists (whose training
focuses on cognitive therapy, as opposed to medicine)
to prescribe psychiatric drugs such antidepressants
and antianxiety medications, provided they get
additional training in medicine and
psychopharmacology. New Mexico passed similar
legislation in 2002.
In a handful of other states, lawmakers are
considering bills that would expand prescriptive
rights for groups including nurse anesthetists, and
optometrists.
The push for prescribing rights comes as professional
groups look for new ways to generate income and expand
their practice. The loosening rules also reflect a
broader shift in the health-care system as more
nonphysicians, from nurse practitioners to homeopathic
doctors, play a larger role in providing care.
But doctors' groups say the looser rules undermine the
standards of the U.S. health-care system. "To have
people with less training prescribing very complicated
medicines creates a quality problem," says Jack Lewin,
chief executive of the California Medical Association,
which represents the state's doctors.
Doctors are generally more receptive to wider
prescribing authority, if providers work as part of a
team led by doctors.
Even some pharmacists are hesitant, citing the
potential for errors and adverse drug interactions.
"You can get into huge trouble when you've got the
dentist, the optometrist, and the nurse practitioner
all prescribing different drugs," says Ernest Boyd,
executive director of the Ohio Pharmacists
Association. In addition, earning the right to
prescribe could mean that nonphysicians see their
malpractice insurance costs rise.
The potential savings are driving some health insurers
to cover the fees charged by pharmacists and other
nondoctors for meeting with patients before they
prescribe. Since California began allowing pharmacists
to dispense the prescription morning-after pill last
year without a doctor's visit, several insurers have
started reimbursing pharmacists for their
consultations with patients. San Francisco Health
Plan, which provides health insurance to low-income
San Franciscans, pays pharmacists $20 each time they
meet with a patient to get emergency contraception.
The company says the rate is far lower than the $250
it would have to pay if the patient went to an
emergency room for the same drug.
"From a health-plan perspective, we don't care who
prescribes it," says Michael van Duren, medical
director of San Francisco Health Plan. "Care should
happen ... in the most cost-effective manner. Not
everything has to run through a doctor's office."
Loosening rules surrounding prescriptive authority can
also open up access to health care. Women's health
advocates, for example, say allowing pharmacies to
dispense the morning-after pill could help prevent
unwanted pregnancies and reduce abortions. The pill
must be taken 72 hours after unprotected sex, and some
women may have trouble getting a doctor's appointment
that quickly. Pharmacies, however, are open on
evenings and weekends and are far more accessible.
(The Food and Drug Administration recently ruled that
morning-after drugs cannot be sold over the counter.)
The federal government has in the past encouraged
expansion of pharmacists' powers, partly to help boost
national immunization rates.
Some drug makers are lobbying on behalf of new
prescription rules. During the past year, Barr
Pharmaceuticals Inc., the maker of the prescription
drug Plan B, an emergency contraceptive pill, has
dispatched lobbyists to drum up support for bills in
Illinois, New Hampshire, and other states that would
allow pharmacists to dispense the pills directly to
patients without seeing a doctor first.
However, other pharmaceuticals companies have avoided
taking sides. Companies that make psychiatric drugs
such as antidepressants and antianxiety medications,
for example, have largely stayed out of the battle
over whether psychologists should be allowed to
prescribe. One reason: Some companies worry they could
face new liability risks if nondoctors begin
prescribing their products, according to the
Pharmaceutical Research and Manufacturers of America,
a major industry trade group, which has remained
neutral on the issue.
The group, however, opposes bills that would let
pharmacists switch patients from one drug to another,
without a doctor's involvement, in part because they
might transfer patients from brand-name to generic
products.
The new state laws mean the nation's prescribing laws
have become a complex patchwork, with wide variation
between professions and states. In New York, for
example, certified midwives with one to two years of
medical training can legally prescribe medications
including antidepressants for postpartum depression
and narcotic painkillers like Percocet to help women
who have had cesareans deal with postoperative pain.
In Georgia, by contrast, doctors still hold nearly all
prescribing authority, and even nurse practitioners
can prescribe only under a doctor's name.
In many states, the new laws have some safeguards in
place, and require nonphysicians to work with at least
some supervision by physicians when they prescribe. In
dozens of states, nurse practitioners and pharmacists
work under "collaborative agreements" with doctors.
That means the nurse or pharmacist can often write a
prescription in their own name, but they work in
partnership with a doctor, whom they can consult in
tough cases.
In other states, certain groups of nonphysicians are
allowed to prescribe only a specific category of
drugs. When the new laws in Louisiana and New Mexico
take effect, medical psychologists will be allowed to
prescribe only psychopharmacologic drugs that affect
the brain, such as Wellbutrin or Xanax. In many
states, nondoctors aren't allowed to write
prescriptions for certain controlled substances, such
as opioid painkillers.
Changing Rules
* In six states, including Maine and Washington,
pharmacists can now give the 'morning-after'
contraceptive pill to patients who haven't seen a
doctor.
* California, Hawaii and Arizona have granted limited
prescribing powers to naturopathic doctors who
specialize in herbal remedies.
* Last month, Louisiana became the second state to
vote to let medical psychologists prescribe drugs like
antidepressants and antianxiety medications.
