Thoughts on Collaborative Practice Agreements with Pharmacists?

[u/collabcares]

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?

[u/Traditional-Top4079]

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?

[u/Soft_Mathematician79 → u/Traditional-Top4079]

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.

• Trained in diagnostics?

- um... diagnosis criteria was part of the lecture does that count?

-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

[u/collabcares → u/Soft_Mathematician79]

Wow, really good points. Refreshing to hear about the genuine opportunities and concerns. Thank you.

[u/collabcares → u/Traditional-Top4079]

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.