NEW LAW LEADS TO CONFUSION ON PRESCRIPTIONS

A new state law allows nurse practitioners to write prescriptions, but many Missouri pharmacists are reluctant to fill them.

Pharmacists say they are concerned about incurring greater liability and waiting on the State Board of Pharmacy to spell out what they should or shouldn't do.

That poses a problem for nurse practitioners such as Nancy Mosley of the Cape Girardeau County Public Health Center's Children's Primary Care Clinic. The clinic, which opened last year, sees about 300 to 400 low-income children a month ranging from 2 weeks to 18 years.

The children are on Medicaid. With area doctors generally not accepting new Medicaid patients, the clinic serves as the only means of health care for these children, outside of hospital emergency rooms, Mosley said.

"I have seen a lot of kids who have never seen a physician since they were 2 weeks old," she said.

The clinic serves residents of Cape Girardeau and Bollinger counties. Currently, there are slightly more than 2,000 Medicaid-eligible children in Cape and Bollinger counties, Mosley said.

Area doctors, she said, have been supportive of the clinic.

Mosley said Tuesday she welcomes the chance to write prescriptions, but with some pharmacists reluctant to fill them she has backed off the idea for now. Instead, she has returned to the practice of calling in prescriptions and giving the name of one of the 13 collaborative physicians who serve the clinic on an on-call basis.

Mosley said that, in effect, she is prescribing the medicine, even though it is being issued under the doctor's name.

Mosley said she hopes the situation can be resolved soon and she can resume writing prescriptions. "I want all the pharmacists to be comfortable with it," she said, "because the primary goal is to take care of the children."

House Bill 564 was approved by the legislature and signed into law by Gov. Mel Carnahan. It took effect on Aug. 28. It allows advanced-practice nurses, working collaboratively with doctors, to prescribe medicine. The law applies to nurse practitioners, certified nurse midwives, clinical nurse specialists and certified nurse anesthetists, said Belinda Heimericks, executive director of the 2,000-member Missouri Nurses Association.

Heimericks said there's been a reluctance by pharmacists statewide to fill prescriptions written by nurse practitioners. But she said, "We are advising them (nurses) to keep writing prescriptions."

Advanced-practice nurses will never replace doctors, but they can extend the delivery of health care, said Heimericks.

Mosley said that at the time the law took effect she hand delivered a letter to area pharmacists explaining the prescription provision and providing authorization from the collaborative physicians.

Mosley said she wrote prescriptions for about a week, but halted the practice in early September after some pharmacists expressed reservations about it.

"It's a gray area," said Ben Tally, pharmacist and owner of Medicap Pharmacy in Cape Girardeau.

An inspector with the state pharmacy board advised about 30 pharmacists attending a meeting of the Cape Girardeau County Pharmacists Association last week that they might incur additional liability by filling prescriptions written by nurse practitioners.

Tally said area pharmacists are not concerned about the qualifications of nurse practitioners like Mosley, but rather how the law will be interpreted by the state pharmacy board, which regularly inspects their businesses.

"They are saying it was passed with no regulations. There was no way to regulate it; everything was too vague," said Tally.

"The concern," he said, "is what a bunch of bureaucrats are thinking."

Pharmacy board officials could not be reached for comment.

Tally said it's his understanding the state is working to resolve the matter. "The state inspector told me it is going to be worked out."

Tally said he supports the idea of nurse practitioners being able to prescribe medicine, particularly in rural areas where there's often few doctors and limited health care.

Mosley said she prescribes medicine in cases involving relatively minor illnesses such as ear and skin infections.

Before the clinic was established, minor infections were clogging the Cape Girardeau hospitals' emergency rooms, she said.

Advanced-practice nurses have had considerable medical training, she said, as witnessed by the fact that most are 40 to 49 years of age.

Nurses in 44 states now have prescriptive authority of some sort, Mosley said.