Wing was quick to point out that the leadership in the effort was always taken by the College. “It was appropriate that the College, as the regulatory body, should take the lead, but RxA was enthusiastically involved at every step of the way,” she adds.
Wing also notes that though the two organizations had for years been contemplating an increased role for pharmacy, the opportunity to bring it about only came when it seemed the community was ready to accept it and the political climate was favorable. Progress was made in stages.
Wing, who has been a member of the management staff of RxA since 2007, was appointed to the CEO position in April 2010. She says the major breakthrough for the profession came in 2007, when, after much preliminary discussion and negotiation with the Alberta Department of Health and its minister, new legislation amended the Health Professions Act and the Pharmacy and Drug Act. The amendments enabled a pharmacist who had completed appropriate orientation to adapt a prescription that did not involve narcotics. In 2009 further amendments authorized pharmacists who had taken the appropriate training to administer injections and monitor ongoing therapy.
The adaptation powers included altering dose formulation or regimen, therapeutic substitution, issuing a prescription for continuity of care and prescribing in an emergency. The additional prescribing authorization is based on the pharmacist’s assessment at initial point of access, such as primary care; collaboration with another authorized prescriber (for example, in chronic disease management); or collaboration with regulated health professionals who do not have prescribing authority.
Wing describes these powers as the really significant foundational pieces that started the movement to the larger expansion of pharmacists’ scope of practice. Some pharmacists completed the College-approved orientation courses that were required before they could provide their patients with these new services. Yet many were deterred from preparing to deliver them because no compensation for their provision was offered by public or private insurers.
RxA had been advising the Alberta government that pharmacists could not be expected to deliver these new services and expend the time and assume the professional responsibilities involved unless they were appropriately compensated. The government, in turn, appeared to appreciate that without pharmacists playing the part that the legislation opened for them there would be no commensurate reduction in the work load of the other health care professions. Accordingly, in 2009 Alberta Health and Wellness provided a $9 million grant to finance the Pharmacy Practice Model Initiative.
This trial, administered by RxA, ran from March 2009 to June 2010 and was intended to establish what fee levels would be fair for community pharmacy in delivering the newly authorized services. The study produced the data that was needed to establish a realistic level of fees. However, the leaders of RxA recognized that a lot of preliminary work had to be done with the other professional bodies and with the government itself before it would be realistic to expect the parties involved to be comfortable with a fee schedule that would act as an encouragement for pharmacists to apply the new powers that had been accorded to them.
In the years from 2009 to 2012 RxA was heavily involved in discussions on the new role of pharmacists with the leaders of other health care professions, particularly the physicians’ and the nurses’ associations. RxA was also working at the political level to ensure that what it might be able to negotiate would be acceptable politically.
Acceptance of the fee schedule that was eventually negotiated among RxA, Alberta Blue Cross, and Alberta Health and Wellness was facilitated as a result of the savings to the government resulting from its successive mandatory reductions on the charges pharmacists made for generic drugs. Alberta Cabinet eventually supported Minister of Health Fred Horne’s recommendation that 50% of the savings from this initiative be applied against non-physician-provided services, including, of course, pharmacist fees for services. The pharmacy fee schedule was implemented in 2012.
“If it had not been for the two years of work we put in with all the parties involved, the minister would have had nothing to announce,” Wing comments. “In the last two and a half years we have not been idle either,” she adds. The pharmacists’ remunerated activities have been extended to deal with issues like trial prescriptions, refusal to fill, smoking cessation, provision of a care plan. “I think it is important to comment,” says Wing, “that in relation to all the new functions the regulations provide that what the pharmacist is remunerated for is the patient assessment that precedes the actual treatment or activity. That means that it is easier to create change without having to go into close detail of a particular service or function.”
Wing says RxA signed a memorandum of understanding with the Alberta government in June 2014 in which RxA is the party responsible for operating the remuneration system from the pharmacists’ point of view.