Increased Scope of Care and the Ultimate Paradigm Change: Team-Based Care

Beneath the Surface of Healthcare Bill HR 4190
August/September 2014, Vol 2, No 4 - Inside Healthcare
Robert E. Henry

HR 4190 is awaiting passage in Congress with importance to pharmacists, but not for its provisions, which would have little effect on most pharmacists. This segment addresses the strategic factors underlying the rhetoric about HR 4190. For it has been positioned by the American Pharmacists Association (APhA) and the Patient Access to Pharmacists’ Care Coalition (PAPCC), as part of an agenda of expanding pharmacists’ scope of practice, which merits keen understanding.

The bill does virtually nothing to expand pharmacists’ scope of practice; its provisions touch on it only peripherally. The APhA and PAPCC are using HR 4190 as a point of reference to raise support for expanding pharmacists’ scope of practice, based on the premise that current strictures on pharmacists’ involvement in treating patients fail to tap into the full measure of pharmacists’ capabilities and do not address the shrinking physician workforce levels and societal needs. Clearly, the strident tone of a current post in the Pharmacists Provide Care section of the APhA website merits examination, for the message is delivered with the unmistakable firmness of pursuit of a mandate for change to the system, not support of an isolated bill:

“Pharmacists are not currently recognized as healthcare providers under federal law, despite having more medication education and training than any other health care professional. Beyond being unfair to our profession, this lack of federal recognition restricts the contributions pharmacists can make to improving patient care.

That’s why APhA has embarked on a campaign to achieve ‘provider status,’ which will recognize pharmacists as valued members of the health-care team, and allow us to use our unique skills and extensive education to enhance patient health. Join Pharmacists Provide Care, and demand to be recognized!

Current Status: On March 11, 2014, HR 4190 was introduced in the House of Representatives by Congressmen Brett Guthrie (R-KY), G.K. Butterfield (D-NC), and Todd Young (R-IN). HR 4190 amends Title XVIII of the Social Security Act to enable patient access to, and coverage for, Medicare Part B services by state-licensed pharmacists in medically underserved communities. Translation: A bill that would recognize pharmacists as healthcare providers! Contact your member of Congress today and ask him or her to support and cosponsor this bill!”1

Rather than berate the APhA and PAPCC for reading too much into this modest bill, it turns out that, upon examination, the substance of the matter does lie in the rhetoric surrounding the bill rather than the bill itself.

At Issue: The Healthcare Provider Paradigm in Transition
Turning our attention accordingly, there is ample evidence that the healthcare provider paradigm is indeed undergoing changes both remarkable and necessary to the roles, responsibilities, and contributions of pharmacists to the process of care.

What is more, expanding pharmacists’ scope of practice to provide many primary care functions previously performed only by physicians is not an isolated agenda, but one tied to several other ambitious changes in the healthcare paradigm: team-based care, the transformation of the retail pharmacies into healthcare delivery companies, the explosion of knowledge concerning wellness, personalized medicine, drug optimization, and the ominous condition of multimorbidity that is experienced by aging patients.2 These factors combine to form a new dynamic in healthcare that inevitably calls for expanding the scope of practice of pharmacists, while also changing the provider model from the solo practitioner to team-based care as patient conditions warrant.

The significance of this multidisciplinary team-based provider model—outlined in the 2012 Discussion Paper by the Institute of Medicine (IOM)3—cannot be overstated. Team-based care entails assigning a multidisciplinary team to care for patients requiring special care according to their unique needs, which may range from multimorbidity to drug optimization with advanced biologics to counseling needs. These clinical provider teams are extraordinarily heterogeneous in their makeup, leadership, and outcome strategies. One common thread, however, is the increasing demand for participation of and often the team leadership by clinical pharmacists to manage patients with multimorbidities requiring complicated drug regimens.

An immediate consequence of team-based care is elimination of turf wars between pharmacists and physicians competing for solo treatment of the same patient. This model also fits the type of medical care required for many of today’s aging baby boomers suffering from multiple, not single, chronic disease states—exceeding the ability of a single physician to manage the patient alone. For a hard fact of medical progress is that most medications manage symptoms without curing the disease state, which can impact other chronic diseases and requires attention.

The joint attention/expertise of a multidisciplinary provider team is suited to the patient’s personalized needs. This scenario demands drawing together the specialized skill sets of multiple healthcare providers, and the IOM Discussion Paper’s overview reveals a picture of extraordinary diversity in the makeup of clinical-based teams.

The Road to Team-Based Care
The expanded scope of practice is warranted for not only pharmacists, but nurse practitioners, physician assistants, and other healthcare specialists where team-based care is needed. As realization of the necessity and effectiveness of team-based care expands, barriers between provider groups are dissolving spontaneously—just as the site of care is expanding from always being treated in a physician’s office to the alternative location of the pharmacy retail clinic, which is fast becoming recognized as individual healthcare companies that likewise employ diverse providers.

Making the Change from Tradition: A Daunting Tactical Restructuring
This segment of our healthcare policy column provides a schematic of the gap between the provisions of HR 4190 and the agenda it really signifies without stating it literally. The fact being that indeed the innermost factor in play here is not only increased scope of practice, but team-based care that requires pharmacists to have increased scope of practice as a means to that end.

Of particular interest remains the specific tactical details of these issues that are intersecting to forge a new healthcare system paradigm, such as making optimal use of resources and body of biologic and pharmacologic knowledge, increased scope of practice of nonphysicians, team-based care, the epidemiologic situation of multimorbidity and its demand for multidisciplinary team-based provider care, and the growing transformation of retail pharmacies into healthcare delivery companies.

One thing is for certain: this is not your father’s drugstore anymore, nor is it being run by your father’s pharmacist.


  1. Pharmacists Provide Care. Provider Status. American Pharmacists Association. Accessed August 8, 2014.
  2. Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307:2493-2494.
  3. Mitchell P, Wynia M, Golden R, et al. 2012. Core Principles & Values of Effective Team-Based Health Care. Discussion Paper. Institute of Medicine, Washington, DC. Accessed August 24, 2014.
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