Using the Theory of Planned Behavior to assess community pharmacists' intention to prescribe using the Formulary and Protocol Compendia.

BACKGROUND: Oregon pharmacists can autonomously prescribe hormonal contraception, naloxone, and various medications and devices from a Formulary and Protocol Compendia (FPC). Prescribing using the FPC has seen limited uptake. OBJECTIVES: (1) Assess Oregon community pharmacists' intention to prescribe using the FPC; (2) Determine the impact that attitudes, subjective norms (SN), perceived behavioral control (PBC), perceived obligation, and past prescribing behavior have on pharmacists' intention to prescribe; (3) Examine the relationship between beliefs and pharmacists' attitudes, subjective norms, and perceived behavioral control. METHODS: This study was conducted as a cross sectional survey, which was developed based on the results of a previously conducted research project. A modified version of the Theory of Planned Behavior (TPB) was the study framework. All Oregon community pharmacists with a public email address were invited to participate. The questionnaire collected information on TPB constructs as well as demographic and practice information. TPB constructs were measured directly (intention, attitudes, SN, PBC, perceived obligation, and past prescribing behavior) and indirectly (attitudes, SN, and PBC). Descriptive statistics were used for all items. Multiple linear regression was used to assess Objectives 2 and 3. RESULTS: There were 175 useable responses included in the analysis of the estimated 1015 community pharmacists that received the survey invitation (17%). Respondents had 16.5 ± 13.3 years in practice, 60% held a PharmD degree, and 69% had prescribed in some manner before. Mean intention to prescribe using the FPC was 5.0 ± 1.5 (7-point scale with 7 indicating higher intention). Attitudes, SN, PBC, and PO were significant predictors of intention to prescribe, while past prescribing behavior was not (Adj R2 = 0.741, p < .0001). Attitudes were explained by beliefs about increasing patient access (p = .0179). PBC was explained by beliefs about having policies and procedures in place (p = .004) and feeling comfortable prescribing (p = .008). CONCLUSIONS: Oregon community pharmacists have a positive intention to prescribe using the FPC, but actual uptake remains low. Efforts to increase uptake should focus on the beliefs that contribute most strongly to pharmacist intention.

Pharmacists' intention to prescribe under new legislation.

BACKGROUND: In 2017, Oregon passed legislation that authorized pharmacists to autonomously prescribe specified medications or devices that were included on the Formulary and Protocol Compendia (FPC). Factors that impact pharmacists' intention to prescribe from the FPC are not currently known. OBJECTIVES: Identify factors that influence pharmacists' intention to prescribe. METHODS: The Theory of Planned Behavior (TPB) served as the framework. Three focus groups were conducted with Oregon pharmacists between May and June 2019 to elicit salient beliefs about prescribing related to TPB constructs, including attitudes, subjective norms, perceived behavioral control, and perceived obligation. Two investigators conducted a qualitative content analysis and reached agreement on names of categories during consensus meetings. A codebook was created after analysis of the first focus group and used to guide the remaining analysis. Participants reported background information and awareness of prescribing rules via a questionnaire; descriptive statistics were used to report background information and the prescribing awareness summary score. RESULTS: Thirteen participants had 14.1 ± 10.8 years of pharmacist experience. Most earned a Doctor of Pharmacy degree (84.6%) and worked in a community pharmacy setting (61.5%). The mean score on the awareness assessment was 6.3 ± 0.9 (7 = highest awareness). The majority (76.9%) had previous prescribing experience. Attitudes were found to be shaped by behavioral beliefs related to the impact of pharmacist prescribing on patient-centered care and on practice transformation. Normative beliefs were primarily driven by outside groups past experiences with pharmacists and pharmacies. Control beliefs included the following categories: operational readiness; the relationships between comfort, competence, and confidence; and Board of Pharmacy requirements. CONCLUSIONS: TPB was useful for exploring pharmacists' beliefs related to their intention to prescribe using the FPC. Determining the relative importance of these factors in a broader population will enable stakeholders to develop interventions to improve uptake of prescribing via the FPC.

Financial Sustainability of an Oregon Rural Health, Primary Care, and Pharmacist-Run Comprehensive Medication Management Program Through Direct Medical Billing.

BACKGROUND: Although several states recognize pharmacists as providers and allow credentialing, this practice is not recognized nationwide. Following adoption of Oregon House Bill 2028, pharmacists are recognized as providers, allowing "health insurers to provide payment or reimbursement for their services to patients." Before this law, and in several instances currently, pharmacist-run programs were financially justified through soft dollars saved by improving patient outcomes, reducing emergency department use, and decreasing readmission rates. OBJECTIVE: To determine if direct billing of third-party payers covers the direct cost of a comprehensive medication management (CMM) program in an ambulatory rural health adult population with uncontrolled diabetes or hypertension. METHODS: This study of a population derived from 2 Oregon rural health primary care clinics was a retrospective chart review of adults (aged ≥18 years) with a primary diagnosis of diabetes mellitus or hypertension who completed a CMM visit with a clinical pharmacist from March 2017 to June 2018. In determining the financial sustainability of a pharmacist-run CMM program, the following primary outcomes were evaluated: (a) percentage of visits completed per insurance type; (b) median reimbursement rate (dollars per visit) per insurance type; and (c) the estimated number of visits per day to cover 100% of the total CMM cost annually. The secondary outcome was the percentage of the major third-party payers that allowed credentialing of pharmacists. All outcomes were evaluated using descriptive statistics. RESULTS: 664 CMM visits were included. Visits per insurance type comprised Medicare Advantage (34%), traditional Medicare (25%), Oregon State Medicaid (20.9%), commercial (17.8%), and self-pay (cash; 1.4%). Median reimbursement rate (dollars per visit) was highest from Oregon Medicaid, followed by Medicare Advantage, and lowest among commercial, self-pay (cash), and traditional Medicare. Total reimbursement received throughout the duration of this pilot project covered 14.1% of the total CMM program cost. It was estimated that approximately 17 visits per day are needed to cover 100% of the total CMM cost annually per pharmacist relying solely on direct revenue within these clinics. Currently, of the 18 contracted insurance companies, only 50% recognize and allow credentialing of pharmacists as providers. CONCLUSIONS: Pharmacist-run services within the 2 rural health primary care clinics were not financially justifiable via direct billing of third-party payers alone. The lack of credentialing, recognition of pharmacists as providers, and reimbursement is inadequate for program expansion and sustainability without relying on additional revenue streams or benefits from improved patient outcomes. Currently, federal insurance significantly contributes to this lack of funding. DISCLOSURES: No outside funding provided support for this research; however, funding from Willamette Valley Community Health was given in the form of a grant to partially fund the comprehensive medication management pilot program. Pharmacists were paid from this grant, while Sublimity Pharmacy compensated pharmacists in the form of benefits. The authors have nothing to disclose. This work was presented in part as a poster at the ASHP Midyear Clinical Meeting; December 4, 2018; Anaheim, CA, and as a peer-reviewed podium presentation at the Northwestern States Residency Conference; May 4, 2019; Portland, OR.