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    States extend prescription-writing powers to growing range of non-physicians


    States extend prescription-writing powers to growing range of non-physicians

    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.
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    Nebakanezer is offline Agnostic Member 510 points
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    Who want's to place a bet on how long it takes before bodies start piling up as a result of these programs?

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