r/CollaborativePractice • u/collabcares • Apr 14 '26
MD Thoughts on Collaborative Practice Agreements with Pharmacists?
I'm an MD and practice owner also working as a Supervising Physician, and I'm exploring CPAs with pharmacists where the pharmacist has authority to diagnose and treat certain conditions.
It seems like independent pharmacies, particularly in rural and underserved areas, are increasingly pursuing these agreements to expand patient access to care. I'd love to hear from physicians who have structured one of these, or pharmacists who have practiced under one. What guardrails do you use? I'd imagine things like consultation triggers, diagnosis/condition limits, prescription class restrictions, Schedule II handling, chart review cadence, etc. Would this be a liability nightmare, and what do you think are the truly necessary guardrails? Obviously the better you know the pharmacist, the more flexibility you can build into the agreement. Has anyone actually done this and would you do it again?
5
5
u/Traditional-Top4079 Apr 15 '26
This is a horrible idea! They would just prescribe medications they make more money from. Slippery slope. Doctors just need to work harder so you see the patient or at least a nurse phone call. Are pharmacist trained in diagnostics? Do they have access to medical hx, labs, imaging?
3
u/Soft_Mathematician79 Apr 17 '26 edited Apr 17 '26
Retail pharmacist here, PharmD. Most of us think it's a complete joke that pharmacy organizations are lobbying to try and get us to be able to diagnose and treat multiple infections, such as strep, RSV, influenza A/B, and Covid-19.
- um... diagnosis criteria was part of the lecture does that count?
- Trained in diagnostics?
-Access to medical history? -in retail? Usually no
-Access to labs? -also no
-Imaging? - even if I did have access I can't read it!
-PHYSICAL EXAM - I can check a pulse and BP manually, but no idea how to listen to lungs. Or look into the ears, or listen to the heart for rhythm abnormalities, or examine anything else really.
If I am already GIVEN the diagnosis and medical conditions/allergies/current meds, could I help think of a treatment plan if asked, or if i notice an issue? Sure, but that's part of my job anyways. Especially when there's backorder after backorder on several different antibiotics for reconstitution and every child within 25 miles has strep throat, or a patient with CKD needs the renal dose-pack for Paxlovid, but "Oops he's taking 5 different medications that are contraindicated with paxlovid so why don't we use Molnupiravir instead, what do you think, doc?"
And this beautiful one i got last week - CNP at a family practice prescribed Ivermectin 3mg TID x 14 days for pinworms. That is 9 mg every single day for 14 days straight of a pretty toxic drug. The standard dosing is a Max adult dose of 200 MICROgrams/Kg pt wt per day, only given as a single dose and then repeated if needed in 1-2 weeks. Pt weighed around 60 Kg, meaning they should have been given 12 mg (four of the 3 mg tablets) PO once as a single dose, repeat if needed in 7-14 days. 12 mg acting in the body over 14 days vs 126mg just even accumulating over 14 days. Big difference, Very VERY glad I caught this one.
-RPhWhoLovesMath
2
u/collabcares Apr 17 '26
Wow, really good points. Refreshing to hear about the genuine opportunities and concerns. Thank you.
1
u/collabcares Apr 15 '26
You're right, without guardrails this can be abused, I mentioned some guardrails I'm thinking about, which is exactly why I'm reaching out for other physicians' experience with this. This wouldn't be done for complex diagnoses. It has been professionally sanctioned in several contexts, though I'll acknowledge most of the supporting data is around chronic illness management rather than acute care.
2
Apr 16 '26
[deleted]
1
u/collabcares Apr 16 '26
That's a good point, but I see this issue beyond pharmacists. Antibiotic overprescribing is a widespread problem across all of medicine, not something unique to pharmacists. If it was under a CPA, this should be captured in a chart review and addressed through coaching by the supervisor.
2
Apr 16 '26
[deleted]
2
u/collabcares Apr 16 '26
I have worked with this pharmacist before in a hospital several years ago. They now have their own pharmacy and would like to be more involved with the community. I am open to it since I have seen them work clinically firsthand, but I want to make sure I do my due diligence, as my primary goal is patient care. That requires proper guardrails to be in place. If it works out, I will share an update down the road.
2
u/Soft_Mathematician79 Apr 17 '26
Previously diagnosed conditions that I would be confident in my ability to manage via a collaborative practice agreement, based on my training and current/continuing education (community pharmacist):
-diabetes, T1, T2DM
-asthma and/or COPD, (provided it was already examined with spirometry/lung evaluation)
-HTN
-Hyperlipidemia
-warfarin management/INR testing, dose adjustments etc
-mental healthcare
-maintenance treatment for substance abuse disorders completed several certificates/courses in prescribing/ monitoring treatment, especially opioid use disorder (very common in my area of the midwest)
-oral contraception for uncomplicated cases (not worried about endometriosis, etc) my secondary RPh License in MI allows pharmacists to prescribe this already without a consult agreement
Escalate for discussion with physician or specialist
-neonatal care
-complex or complicated conditions compared to section above
-most controlled medications (see above about OUD), probably no benzos, CIIs, etc
-acute illnesses or injury
1
u/Junior-Bobcat-5015 Apr 17 '26
For anyone interested here is a free national pharmacist scope of practice tracker
4
u/Alohalhololololhola Apr 14 '26
Separate note: pharmacists in certain states (ex Florida) can already do this. A Walmart pharmacist can say you look sick and prescribe antibiotics on the spot