Advancing Scope of Practice: New Mexico

Speaker 1:   Welcome to the ASHP Official podcast, your guide to issues related to medication use, public health, and the profession of pharmacy.

Tom Kraus:  Thank you for joining us for the ASHP Advocating For Impact podcast, where every episode covers a policy issue impacting the practice of pharmacy. We'll do our best to translate the politics and the legal lingo to help you understand how these issues affect your practice and your profession. Today we're recording from the 2019 Midyear Clinical Meeting in Las Vegas. I'm Tom Kraus. I lead the government relations team at ASHP.

Tom Kraus:  Today I'm joined by Joe Anderson and Melanie Dodd from New Mexico and we're going to have a conversation about how New Mexico has approached advanced pharmacy practice and expanded the scope of practice for pharmacists. Dr. Anderson currently is the assistant dean for curricular affairs and an associate professor of pharmacy practice at the University of New Mexico College of Pharmacy. He's also an associate professor of internal medicine at New Mexico School of Medicine.

Tom Kraus:  His area practice is in cardiology and he is a licensed pharmacist clinician. Dr. Dodd is associate dean for clinical affairs and associate professor for geriatrics at the University of New Mexico College of Pharmacy. She's a pharmacist clinician with prescriptive authority at the University of New Mexico Senior Health Clinic, providing chronic disease and medication management for older adults, and has been doing that for 15 years.

Tom Kraus:  She's also a consultant for community-based hospice services. She's responsible for extensive didactic and clinical teaching activities in a Doctor of Pharmacy program at the University of New Mexico. So thank you both for joining me today. So I think it's helpful for listeners, especially those from other states, to understand how the scope of practice for pharmacists in New Mexico evolved and how that might serve as a model for other states. My understanding is that, going back several years, back in 1993, the legislation was passed that dramatically changed the scope of practice and clinical services that pharmacists could provide. Can you tell us a little bit about how that is structured?

Melanie Dodd: Absolutely. So New Mexico is a very rural state. We're the fifth largest state in the country with a little over 2 million people in population, so we're very scattered in terms of our population, and access to healthcare has been a longstanding health issue. Going back to 1993 we were able to, as a profession, to pass a legislation in the state, which was called the Pharmacist Prescriptive Authority Act, which changed the way that a pharmacist potentially could practice.

Melanie Dodd: It's increased our clinical services through a collaborative practice agreement and created the pharmacist clinician license. That license requires additional training for a pharmacist licensed in New Mexico, which includes completion of a 60 hour physical assessment course, followed by 150 hour, 300 patient contact clerkship experience with a prescriber. They then must be licensed with both their New Mexico Board of Pharmacy as well as with our New Mexico Board of Medicine under which they have an approved supervising physician, as well as an approved prescriptive protocol under which the pharmacist clinician can then practice. Those pharmacist clinicians are then able to practice in all variety of settings. It could be in an ambulatory clinic, could be in an inpatient setting, and everything in between. So we're not limited in terms of the setting or the population for which we care for within that practice model. And the supervising physician just has to be accessible, but they don't physically have to be in the same site as that pharmacist clinician.

Tom Kraus:  And Melanie, you mentioned at the outset that some of this was undertaken as a way to impact rural care. Can you just say a little bit more about how this authority has impacted care provided in rural settings?

Melanie Dodd: I would say definitely that we do have pharmacist clinicians in some rural areas. I would say the majority of our pharmacist clinicians are in our metropolitan areas of Albuquerque, some in the southern part of the state in Las Cruces, but there definitely are some pharmacist clinicians in some of those other rural areas. But it's definitely been a challenge because of some reimbursement and other financials to be able to really expand the model.

Tom Kraus: Joe, can you tell us a little bit more about some of the motivations behind the development of the pharmacist clinician? I'm particularly interested in how physician shortages plays into the role of pharmacist in these more advanced practice roles.

Joe Anderson: Sure. Yeah. As Melanie mentioned, our state is large and very rural. And in fact I think 31 of our 33 counties are designated as primary current health professional shortage areas. So we definitely suffer a lack of primary care providers, particularly in those rural areas. And so the original legislation was intended to sort of bridge that provider gap by empowering pharmacists who are practicing in rural areas to practice at a little bit higher level and sort of ease the shortage of primary providers. Unfortunately, as Melanie mentioned, it seems that most of the pharmacist clinicians have congregated into the urban areas of New Mexico. And I think we're going to talk about some of the barriers, but certainly the lack of provider status has been a large barrier to why more pharmacist clinicians are not practicing in more of the rural areas, which was the original intent.

Tom Kraus:  Well, so let's, let's talk a little bit more about that then. What has been the barriers to a broader use of the pharmacist clinician, whether that's educational or whether that is reimbursement?

Melanie Dodd: I would say that the-

Joe Anderson: Oh, go ahead, Melanie.

Melanie Dodd: I would say the biggest barrier has been lack of federal provider status and the ability to reimburse. We have been successful in our state in achieving provider status under Medicaid for our pharmacist clinicians, but that is only extended to a fee for service Medicaid population. We have a predominantly managed Medicaid population in our state, so we haven't been able to expand that provider status into the managed Medicaid population, so that reimbursement continues to be a barrier.

Tom Kraus:  And outside of managed Medicaid and the commercial population, I assume there's also an interest in identifying reimbursement opportunities there?

Melanie Dodd: Absolutely, absolutely, and certainly commercial. We have had some limited successes with commercial plans and having individual contractual agreements to provide select services, but that certainly has not been across the board for all healthcare providers and health systems, nor all payers. So that continues to be a barrier.

Tom Kraus:  So Melanie, are there particular policy approaches New Mexico is pursuing to help address some of these reimbursement gaps?

Melanie Dodd: I think two fold as we look at opportunities to be able to address that barrier. One is certainly having conversation with our Medicaid leadership to be able to look at expansion from just fee for service to include managed Medicaid. So that's certainly one of our conversations with hopefully being able to have pharmacist clinicians embedded into the Medicaid budget for the state, which will then allow that expansion within the Medicaid population.

Melanie Dodd: The other is looking at legislation that would be in line with several other states in terms of having a parity of reimbursement for pharmacist clinicians as well as pharmacists that have independent perspective authority in certain areas, such as immunizations and hormonal contraception. So that will be a legislation that we introduced in 2019 that had fairly good progression on our house side, but unfortunately we ran out of time in our legislative session and we're looking at reintroduction of that bill in our 2020 session.

Tom Kraus:  And have you seen support from other clinicians, from physicians for the role of the pharmacist clinician, and in fact reimbursement for those services?

Melanie Dodd: I would say we absolutely have that support. I think one of the important lessons that we had early on, going back to 1993 when you had the original pharmacist clinician statute, was it was very important for us to, from a grassroots perspective, to have that support of all of our board, medical board as well as our New Mexico medical society, make sure we have that physician support.

Melanie Dodd: And then moving forward as the model has been enacted, especially in the health systems where we have a number of pharmacist clinicians in those settings, we've definitely developed those relationships not only with our physicians, but our nurse practitioners and physician's assistants and our entire interprofessional team, and certainly have come to that time where they rely on pharmacist clinicians in those settings, using other types of financial models to be able to support them. But certainly because of the lack of provider status, not able to be able to expand.

Tom Kraus:  And it sounds like that's an important learning for other states as they pursue expansive scope of practice and reimbursement. They need to make sure that they are working with the physician community both in clinical practice, but also the associations that represent those physicians to make sure there is a body of political support for expansion of scope of practice.

Melanie Dodd: Absolutely.

Joe Anderson: I was just going to add another stakeholder to make sure to involve would be the Board of Nursing. And we actually did involve the Board of Nursing as well as the Board of Medicine prior to introducing the legislation to make sure that they were on board in terms of supporting either the legislation.

Tom Kraus:  Yeah, that makes a lot of sense. And Joe, I'm curious how pharmacy education has needed to evolve to meet the needs of this new role of a pharmacist in New Mexico. How have schools of pharmacy addressed that?

Joe Anderson: Yeah, that's a great question. And what we've been able to do here at the College of Pharmacy is actually be involved with the initial bills that were introduced, as well as to be involved with the training requirements that were agreed upon by the medical board, the nursing board, and of course our board of pharmacy. And then incorporate those trainings into our curriculum such that our graduates are eligible to practice at that highest level. The slight exception would be the pharmacist clinician, which Melanie mentioned I think previously, but it does require the additional 150 hour patient clerkship, and that has to be obtained after graduation by our pharmacy students or graduates.

Tom Kraus:  I see. But it sounds like there are some core elements of education that can be built in to prepare a pharmacy students to be providing these kinds of clinical services.

Melanie Dodd: Yeah, absolutely. So all of our students through our current Doctor of Pharmacy curriculum at the University of New Mexico are provided with the training for the independent prescriptive authority components. So they're, upon licensure as a registered pharmacist after graduation, they are able to have that independent prescriptive authority for elements like immunizations, hormonal contraception. So those are components that are built into our curriculum. And then they have the opportunity to take the 60 hour physical assessment course as an elective course prior to graduation, but then after graduation they would still need to do that patient contact hours.

Tom Kraus:  And how has the role of advanced practice pharmacists been accepted by patients and what's occurred to kind of increase the visibility of pharmacists as providers of direct patient care in the community?

Melanie Dodd: I would say within the University of New Mexico hospitals, as well as other large systems within our community, patients have come to expect to receive some of those services, to be able to see their pharmacists for chronic disease management, for their diabetes management, their hypertension management, medication related problems. We continue to expand and educate our patient population in terms of those resources.

Melanie Dodd: I think in certain settings where they've had those opportunities to work with a pharmacist clinician, they wouldn't go back because they really appreciate that expertise that that pharmacist clinician brings to the table that none of their other healthcare providers have as they come to the table. But it's absolutely an area that we need to continue to educate in terms of the role of pharmacists and pharmacist clinicians in terms of what we can provide and to have pharmacists expect that. I think we've certainly done that in our community practices where patients now think about going to the pharmacy to get their flu shot, while we go back in time, they would have always gone to the physician's office. So we've definitely, we've changed the dynamic from that perspective and we need to continue to do that [crosstalk 00:15:50]

Tom Kraus:  Expectation and perception of patients, yes. Great. So Joe, earlier we talked about some of the approaches in collaboration with other clinician groups to advance this legislation. Is there anything else that was done to advance legislation in particular? How were individual pharmacists in the state involved in advocating that? On this podcast, we're very interested in how we can enhance the advocacy experience for pharmacy.

Joe Anderson: Yeah, I think that's a great point for all pharmacists to understand is the power they have, particularly in these rural states where your representative, and many, many pharmacists know their representative or their senators. And so the power of reaching out to them, inviting them for a site visit, that just really speaks volumes to changing those perceptions as we mentioned earlier. And then just the power of calling when a bill is introduced.

Joe Anderson: And so we've, through the New Mexico Society of Health System Pharmacists, our legislative committee, whenever there's a bill that's out, we send out information to please contact your representative. And I think our pharmacists this last year, Melanie mentioned that the bill that was introduced in the house at this last session, our pharmacists did a great job of phoning their representatives.

Joe Anderson: Melanie had the privilege of testifying for the bill at the legislature. And one of the legislators said, "Oh yeah, this is the bill that I'm getting all these phone calls from." So we know it works when the pharmacists do activate and call their representatives. You may think, "Oh, they're not paying attention. I didn't actually speak to the representative." But their staff are tallying those phone calls and then they're letting their representative know, "This is a bill of interest to your constituents." So it's very helpful.

Tom Kraus: Yeah. That's incredible to hear. I think we often don't consider the impact that we have as experts and actually as constituents for policymakers. So that sounds like it's been a great experience. Joe, I'm curious if there's anything else that you would want other states and pharmacists practicing in other states to know as they pursue expansions of scope of practice and reimbursement, in particular advanced practice pharmacy models?

Joe Anderson: Yeah, I think it's important to coalesce all the key stakeholders prior to initiating any type of legislation. So as we mentioned previously, you work with your medical society, work with your nursing board, you're nursing society, and even the PAs, the group, whatever their professional organization might be in your state, because those are all key stakeholders and those are individuals who might feel perhaps a little bit threatened by an advancement in pharmacy practice.

Joe Anderson: So you want to work with them beforehand to sort of put their potential anxieties at ease to let them know that you're not taking patients away from them. You're actually going to work with their patients and help them to improve their patient's care. I think that's critical. That's how most advanced practice pharmacists function. We are team-based providers and I think that's critical to emphasize. And then getting, of course, their support, any concerns that they have, address those prior to taking it to the legislator ... Legislature rather. And then hopefully they won't voice opposition during any particular hearings.

Tom Kraus: Yeah, that makes a lot of sense. Melanie, is there anything else that you recommend folks are attentive to?

Melanie Dodd: I think the other piece that's important, Joe mentioned activating and encouraging pharmacists to be a part of that advocacy process. But I think the other important element in addition to the health care community is also the patient. So if there are patients perhaps that you as a pharmacist have cared for, assuming are they are willing to speak to that. We definitely had powerful patient testimony that definitely speak to the role that pharmacist clinicians have provided in the care of them as individuals or their family. And we even, in this last legislative session, it was fantastic to hear as we were presenting to one of the house committees, there were several of the legislatures who spoke to their own personal experiences that they've had with pharmacists and pharmacist clinicians as they were advocating for support itself.

Tom Kraus:  Wow.

Melanie Dodd: So those were completely unsolicited.

Tom Kraus: That's incredibly powerful I can imagine.

Joe Anderson: Right.

Tom Kraus: Well that's great. So it sounds like as states think about this, they should be really paying a lot of attention and investment in building those relationships with other clinician groups and making there's a sort of united front to advance pharmacy practice. Well, thank you both for joining us today and thanks for letting us learn from the New Mexico experience. I really appreciate it.

Joe Anderson: Thank you.

Melanie Dodd: You're very welcome.

Speaker 1: Thank you for listening to ASHP Official, the voice of pharmacists advancing healthcare. Be sure to visit ASHP.org/podcast to discover more great episodes, access show notes, and download the episode transcript. If you loved the episode and want to hear more, be sure to subscribe, rate, or leave a review. Join us next time on ASHP Official.