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VA may limit pharmacists' scope of practice

A reinterpretation of long-standing policy by the Department of Veterans Affairs could curtail pharmacy practice in VA medical centers around the country. VA pharmacists, advanced practice nurses (APNs), and physician assistants (PAs) are losing the broad prescriptive authority they have exercised in recent years.

Instead, scope of practice in VA facilities will be regulated according to the practice acts in the states in which each practitioner is licensed. "That means every pharmacist in the facility could have a different scope of practice," said Benjamin Dishman, clinical R.Ph. at the VA Medical Center in Carlsbad, Calif., near San Diego. "It's an administrative and practical mess."

The changes were ordered by acting undersecretary of health at the VA, Frances Murphy, M.D. A directive issued on Dec. 31, 2001, called for the changes to take effect by June 30 of this year, but implementing regulations have yet to be published in the Federal Register.

"In clinics, we initiate, modify, and halt drug therapy every day under well-established protocols," said clinical pharmacy specialist Stacey Anderson, who works at a VA medical center in Bethlehem, Pa. "If we have to stop, it is really going to hurt the VA. Some clinics have more than 1,000 patients with pharmacists as providers. Many patients are going to be without their familiar providers."

Pharmacy executives at the VA are equally unhappy with the proposed change in scope of practice. "There are a lot of studies out there, some of them from the VA, that show collaborative practice works extremely well," said Jeff Ramirez, chief of management and clinical information systems at VA's pharmacy benefit management division in Washington, D.C. "We are not asking to be the sole prescribers; we are asking to be part of the collaborative team. Collaborative practice is the way the VA works."

Collaborative practice is not going to change, said a VA spokeswoman. Pharmacists and other nonphysicians licensed in states that allow collaborative practice will be able to continue current projects, subject to state limitations.

"The idea of using state licensure seems reasonable, on the surface," said Larry Ereshefsky, professor of pharmacy and psychiatry at the University of Texas College of Pharmacy. "But the scope of practice in even the most liberal states is more restrictive than standard practices at the VA. This is unabashed turf-grabbing at the expense of programs that have been shown to work extremely well for patients, providers, and the VA itself."

A highly placed VA pharmacy executive who asked not to be identified said the change is a political move by conservative physicians. They want to undo Clinton Administration policies. The current target is a plan by then-undersecretary of health Kenneth Kizer to double the number of providers. Rather than hiring more physicians, he formalized prescriptive protocols that had been created by physicians and pharmacists, APNs, or PAs since the 1970s.

Other VA officials, who also asked not to be identified, said the agency's physician executives are trying to block moves by chiropractors and others to obtain prescribing authority.

Either way, said Gary Stein, director of federal regulatory affairs for ASHP, "VA physicians are trying to flex their muscle. They don't want anybody impinging on their territory. If the change goes into effect, it will destroy clinical practice in VA medical facilities."

Stein said there are signs that the proposed changes in nonphysician prescribing can be stopped, or at least modified. VA secretary Anthony Principi is said to favor wider access to VA health services. That could translate into support for broader prescriptive authority.

Scope of practice may also come up at Senate confirmation hearings for a permanent VA undersecretary for health. And once proposed regulations are published in the Federal Register, the changes are open for public comment. But for now, VA R.Ph.s are scrambling. Ramirez said about 30 states have collaborative practice acts. Pharmacists licensed in other states can use reciprocity to obtain a license in a more liberal state. Anderson said managers are advising pharmacists to reciprocate into Washington, widely regarded as offering the nation's most liberal collaborative practice act.

"We haven't seen a flood of reciprocity applications yet," said Washington State Board of Pharmacy executive director Don Williams. "But we've had many conversations with VA supervisors and individual pharmacists. If VA pharmacists are licensed here, they can continue to do the things they are used to doing."

But there's a catch. At best, obtaining a reciprocal license in Washington takes four to six weeks, Williams cautioned, although the required state law exam can be taken on-line. And a Washington pharmacy license costs about $600. VA has already said that it will not reimburse pharmacists (or other nonphysicians) for any reciprocal licenses they might obtain.

"I'm licensed in three states already," Anderson said. "It's hard enough to keep that much up. I don't want another license. But if that is what it takes to provide the care my patients need, that's what I'll do."

Fred Gebhart

 

Fred Gebhart. VA may limit pharmacists' scope of practice. Drug Topics 2002;6:12.