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Dr. Siobhan Dunnavant
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804-698-7512
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PO Box 70849
Henrico, VA 23255

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Doctor's Note: Pharmacists Scope of Practice

When we talk about health care and fixing our systems, the cost of health care is undeniably the biggest issue for people. Costs create barriers to quality health care. One of the biggest issues we have in medicine is that people are not seeking preventative care. Many people do not even have a primary care physician. To both lower cost and increase access to care, I am proposing that some services be made available at your local pharmacy. My legislation, SB1026, makes it easier for pharmacists to dispense medications that are covered by their insurance for wellness and safety interventions.


There are many medications that could help prevent illness, or medications that need to be available emergently that pharmacists have more than enough expertise to dispense without a prescription or office visit. A few examples of these medications are: epinephrine for an anaphylactic allergic reaction; narcan to reverse a narcotic overdose; smoking cessation medications; and vaccines. Pharmacists are experts on the side effects of medications. They can ensure that patients have clear, written instructions about side effects and complications they should know about and when to see a doctor.


This is a change, maybe even a big change, but many other states have already expanded what pharmacists can do. In Europe, pharmacists do a lot more than we allow for in the United States and it works well. To be seen in a medical practice, it usually requires an appointment, time off work, a co-payment, maybe more if a patient has a high deductible, followed by a trip to the pharmacy afterward. When you need help after office hours, your choices are an urgent care center or emergency room, which pose even greater costs. If there was a way to safely deal with some of these things outside of a medical practice then it could save people time and money. It may even give people with no insurance a low cost option where they can get something that can make them better or safer instead of a complete barrier to access.


A pharmacist does not diagnose. A pharmacist also does not provide medical care or wellness care, but they can be a part of a system seeking to help patients. In Virginia, we have something called “collaborative agreements.” These are written guidelines between a specific doctor or nurse practitioner for a series of protocols that direct pharmacists making decisions about dispensing that do not require an additional medical visit or prescription change. These collaborative agreements work and save money, time, and cost for patients.


What I am proposing are basically state-wide collaborative agreements between all licensed practitioners and pharmacists with very clear protocols that ensure safety. Those protocols would be developed over the next year by the State Boards of Medicine and Pharmacy. This bill has a delayed enactment clause that will require a review and approval of those regulations before it can become law in 2021.

I think this is a reasonable change that can help with access and cost of health care. Making the system we have work better for patients is going to require uncomfortable change. I think this is the value of having a doctor in the Senate. I can lead that uncomfortable change, while understanding the perspective of the involved health care providers and patients and applying what I have learned in solving problems at the state level.


However, there is one more reason I think this bill is important. We are on the verge of big changes in medicine with many innovations taking place, including telemedicine. We have to make changes because the cost of health insurance and health care is at a crisis point for many Virginians. We need a framework that guides us to be sure these changes are for the good and not just haphazard.


There is one important constant that we should keep in place as we proceed. The best medical care is coordinated care. Someone needs to have all the medical information about a patient; the big picture that all the little puzzle pieces fit into. This is called a “Patient Centered Medical Home” (“PCMH”). The PCMH is a care delivery model where patient treatment is coordinated through the primary care physician to ensure that the patient receives necessary care when and where they need it. Studies have shown this results in the best outcomes and cost savings for the patient-physician or patient-practitioner relationship. The continuity in these relationships matters. There is oversight and efficiencies and a central plan, and it works.


As we look at modifying access, we need to strengthen the concept of central coordination. My legislation requires the Boards to develop regulations including that infrastructure. This bill would require that pharmacies communicate every intervention provided to the primary care doctor. If there was none, they will educate the patient on nearby doctors, free clinics and/or health departments. The provider caring for the patient and coordinating that care would need to verify to the pharmacist that the patient is indeed cared for by that practice. This requires a two-way communication. It’s something we do not do well in medicine, but it is really important. If we can work out a system to do this through the regulations developed as a result of this bill, we can ensure good coordination as medicine becomes less centralized.



SOURCES for Patient Centered Medical Home Info.:

https://healthitanalytics.com/features/breaking-down-the-basics-of-the-patient-centered-medical-home

https://www.health.harvard.edu/blog/patient-centered-medical-home-a-new-model-for-medical-care-2017083012260

https://www.fiercehealthcare.com/practices/how-one-pediatric-practice-transformed-into-a-patient-centered-medical-home

https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=2323