BETHESDA, MD 09 Oct 2013—The road to victory for California Senate bill 493 (PDF) was neither straight nor smooth.
"This was a major fight," said Dawn Benton, chief executive officer of the California Society of Health-System Pharmacists (CSHP).
Meetings between CSHP staff and state legislators or their staff occurred practically every day throughout the legislative process, she said.
But on September 12, after several Senate and Assembly hearings, votes, and amendments over the course of seven months, the bill emerged from the California State Legislature.
And on October 1, Governor Edmund G. Brown Jr. added his signature.
Come January 1, the California government will recognize pharmacists as "health care providers who have the authority to provide health care services."
Furthermore, those pharmacists whom the state board of pharmacy recognizes as advanced practice pharmacists may provide certain additional services.
Teamwork. CSHP and its legislative partner, the California Pharmacists Association, worked in earnest to resolve conflicts with "the opposition," said Jonathan Nelson, government affairs manager for the health-system pharmacists group.
The pharmacist groups succeeded in part, he said, by explaining some of the bill's provisions in terms clearer than in earlier versions.
Even the California Academy of Family Physicians and the California Medical Association (CMA) had removed their opposition by the time the bill headed to the Assembly floor.
Hundreds of CSHP members wrote letters to their legislators, Nelson said. Many members in addition helped with the financial part of the legislative effort and met with their legislators to explain the contributions of pharmacists on the health care team.
"Their actions really helped pave the way to victory," he said.
Collaboration, not independence. Something the pharmacists purposely did not do was important as well, said CSHP President Steven Gray.
"We did not claim that we were independent in the sense that we diagnose," Gray said. "Pharmacists are not trained to diagnose. So we didn't use the d word in anything."
Similarly, the pharmacists did not claim to provide primary care, he said.
"In the nonpharmacist world," Gray explained, "primary care means that you're the person that sees the patient and diagnoses. We may see a patient first when they walk in the pharmacy, but we refer them to a physician or other diagnostic profession. And then, once they determine what the problem is, we're there to assist with the management of the drug therapy."
More information on the law is available in the nine-page "What Does SB 493 Mean to Me?" fact sheet (PDF) prepared by the two pharmacist groups.
Cooperation. Senator Ed Hernandez, who introduced the legislation, had contacted the pharmacist groups last year and relied on them for the bill's language, Benton said.
His legislation to establish independent practice for nurse practitioners and permit optometrists to diagnose conditions and disorders of the eye, however, are still with Assembly committees.
Benton said the pharmacist groups ensured that their legislation stated the need for communication and collaboration with patients' physicians.
"In our negotiations with CMA, the physicians were very concerned that the pharmacists not be acting independently," she said.
The state's need. Nelson said the California pharmacist groups looked at New Mexico's and North Carolina's legislation on advanced practice pharmacists "as a starting point, as an inspiration."
But both states passed their legislation more than 10 years ago, which meant the California pharmacists could not rely solely on the language in those bills, he said.
After President Obama signed the Patient Protection and Affordable Care Act in 2010, California's government started planning to ease the eligibility requirements for the Medicaid program and implement a health insurance exchange.
"We needed something in California, we felt, to handle the increase in demand for health care both in terms of quantity and complexity," Gray said. "And that was the main reason that we felt that it was imperative to get this bill through and allow pharmacists to be a part of the solution and apply the full breadth of their training and experience."
Commercial insurers' interest in having pharmacists provide collaborative drug therapy management in accountable care organizations was also taken into consideration, he said.
"They were starting to run into problems," Gray said. "They couldn't find enough of the collaborative drug therapy management pharmacists."
A 1994 California law allows certain pharmacists to provide collaborative drug therapy management in health care facilities. Those pharmacists have completed a clinical residency training program or had showed clinical experience in providing direct patient care.
Gray said the number of pharmacists wanting to complete such a residency program has outpaced the openings.
CSHP's members, he said, saw the urgent need for "an alternative pathway."
The new law, in creating the designation "advanced practice pharmacist" and further expanding the scope of pharmacists' practice, adds certification in a relevant practice area as a pathway.
Blue Shield of California, which has accountable care organizations in several areas of the state, supported the bill.
Not done. Benton said CSHP started receiving congratulations from people around the country once word spread about the governor approving the bill.
"We've got a lot of work ahead of us, and we're already getting started," she said.
The state boards of pharmacy and medicine, for example, must agree on the standardized procedures and protocols for pharmacists to furnish prescription nicotine-replacement products. And, as another example, the state board of pharmacy must develop a process for accepting applications for recognition as an advanced practice pharmacist.
Benton said CSHP will participate at every opportunity.