EMERGING PARADIGMS: PHYSICIAN

DISPENSING
Mark A. Munger, Pharm.D., F.C.C.P., F.A.C.C.
Professor, Pharmacotherapy
Adjunct Professor, Internal Medicine
University of Utah

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

PRESENTER DISCLOSURE INFORMATION

I will not discuss off-label use or investigational use in my presentation.
I have no financial relationships to disclose.
Employee of: None
Consultant for: None
Stockholder in: None
Research support from: Utah Legislature and Department of Commerce
Honoraria from: None
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

SELF-ASSESSMENT QUESTIONS
Physician dispensing in the United
States is:

Physicians perceive drug

dispensing as:

A. Rare

A. Reducing the drug cost to my patients

B. Practiced daily or weekly

B. Reducing the cost of healthcare

C. Commonplace across all practice

settings

C. Improving drug adherence

D. All of the above

D. Under the direction of the Board of

Pharmacy in most states
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

SELF-ASSESSMENT QUESTIONS
Physician perception of the highest
burden of pharmacy practice rules on
dispensing practice is:
A. Labeling the prescription bottle
B.

Keeping a medication profile system

C. Drug stock labeling and inventory

control
D. Maintaining prescription and drug
record keeping
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

UTAH PHYSICIAN DISPENSING LEGISLATION

2010 Legislative Session: SB 88 exempted physicians and clinics from pharmacist
and pharmacy licensure if dispensing a cosmetic drug or injectable weight loss drug.

2011 Legislative Session: SB 128 exempted prescribing practitioners from pharmacist

and pharmacy licensure if dispensing a cosmetic drug or injectable weight loss drug.
Prescribing practitioner: licensed physicians, APRNs, PA, and optometrists.

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

UTAH PHYSICIAN DISPENSING LEGISLATION

2012 Legislative Session: SB 161 permitted prescribing practitioners to dispense
certain oncology drugs without a license provided they meet established
requirements.
Required that prescribing practitioners qualifying for a drug dispensing exemption
relating to oncology drugs, selling contact lenses, or cosmetic or injectable weight loss
drugs notify the Division (DOPL) in writing of their intent to dispense a drug
Excluded Schedule I, II, and III drugs from the drugs that oncologists could dispense
Required the Division (DOPL) to conduct a study evaluating:
National compilation of state dispensing laws; and
Current research on non-pharmacist dispensing and patient safety
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

RESEARCH SERIES ON HEALTHCARE

PRACTITIONER DISPENSING 2012
Mark A. Munger, Pharm.D., Michael Feehan, Ph.D., Emily Rumanek, M.A., M.B.A.,
Lynsie Ranker, B.S., Kristen Vincent, Sc.B., Scott Silverstein, Pharm.D., and Jim
Ruble, Pharm.D., J.D.
Collaborative Study Team (University of Utah Health Sciences Center and
Observant, LLC. Boston, MA.)
Funding: State of Utah Legislature and Department of Commerce Grant-in-Aid
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

RESEARCH SERIES: THREE INDEPENDENT STUDIES

I. Healthcare Practitioner Prescribing in 50 State Statutes and Rules
A. Lexus Nexus: Academic Universe
1. Search Terms: Physician, dispens*, Practitioner
B. State Websites for Boards of Pharmacy
C. National Association Boards of Pharmacy Survey of Pharmacy Law 2012

II. Healthcare Practitioner Dispensing of Prescription and OTC Products

A. 379 healthcare practitioners completed a 15-minute online survey in September and October 2012.
B. Nurse practitioners, optometrists, oncologists, dermatologists, and plastic or reconstructive surgeons were selected due
to state of Utah statues.
C. Respondents were recruited by email from an pre-registered (opt-in) online panel to participate in market research
studies.

III.Consumer Perceptions of the Dispensing of Prescription and OTC Products by Healthcare

Practitioners
A. A total of 999 adult consumers in the USA completed a 15-minute online survey in October 2012.
B. All respondents had been dispensed a prescription and/or an OTC product, by a healthcare practitioner in the past 12
months.
C. Participants were recruited by email from an online panel of consumers pre-registered (opt-in) to participate in
market research studies

Non-Pharmacist Dispensing in the US

Allowed (44 States)
Restricted (6 States)
MA no specific law authorizing
MT dispensing prohibited; some exceptions
NJ dispensing allowed; but limited to 7-day supply
NY dispensing allowed; limited to 72 hour supply
TX dispensing not allowed; 72 hour immediate need
UT dispensing limited to cosmetic drugs

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ

Munger MA et al. Pharmacotherapy 2014

PRACTITIONERS QUALIFIED TO DISPENSE

MD, DO, DDS, DPM, DVM, PA, NP

(38 States)

Restricted to MD, DO, DDS, DPM, DVM (6 States)

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ

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DISPENSING PRACTITIONER REGISTRATION

No Registration Required

(28 States)

Registration Required

(16 States)

States require registration with respective professional board, except:

NE register with BoP as delegated dispenser
NH register with BoP as limited retail drug distributor

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ

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COMPLIANCE WITH PHARMACY REGULATIONS

WHEN NON-PHARMACIST DISPENSING
No Specific Dispensing Requirements

(23 States)

Some Dispensing Requirements

(17 States)

Must Follow All Pharmacy Requirements (4 States)

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ

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HEALTHCARE PRACTITIONER DISPENSING OF

PHARMACEUTICAL RX PRODUCTS
QUALITATIVE RESEARCH

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

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METHODOLOGY
Sample targets were n=80 per specialty group split evenly between dispensers (in the past 3
months) and non-dispensers.
Dispensers

NonDispensers

Total

Nurse Practitioners

32

32

64

Dermatologists

40

39

79

Plastic and Reconstructive

Surgeons

39

38

77

Hematologist-Oncologists

27

21

48

Medical Oncologists

13

19

32

Primary Care Physicians

40

40

80

Psychiatrists

40

40

80

Internal Medicine Doctors

41

40

81

311

309

620

Specialty Type

(Family Medicine and General Practice)

TOTAL

RESPONDENTS CAME FROM ACROSS THE COUNTRY

Northeast Region
West Region

Midwest Region

78 (21%)

83 (22%)

South Region
118 (31%)

100 (26%)

DISPENSING IS MOST COMMON AMONG

DERMATOLOGISTS OR SURGEONS
Prevalence of Dispensing by Specialty
Percent
Dispensing

Nurse Practitioners
(n=96)

Optometrists
(n=273)

Oncologists
(n=298)

Dermatologists
(n=207)

Plastic and Reconstructive Surgeons

(n=185)

56%

54%

67%

75%

72%

Rx Dispensing is Done Very Frequently

Frequency of Dispensing Rx Products

(% Rx Dispensers)

100%
1/Three Months
1/ Two Months

6%
2%
10%

34%

1/Month
Weekly

82%
dispense
daily or
weekly
e

48%
Daily

0%
Rx Dispensers
(n=174)

17

OTC Dispensing is Done Very Frequently

Frequency of Dispensing OTC Products

(% OTC Dispensers)

100%
1/three months
1/two months

4%
2%
11%

32%

1/month
Weekly

83%
dispense
daily or
weekly
e

51%
Daily

0%
OTC Dispensers
(n=171)

18

Patients Dispensed Medications Are As Likely

To Be Aged 65+

%HCPs Patients Aged 65+

100%

Patients Aged 65+

(Among Dispensers)

37%

33%

32%
e

0%
General Non-Dispensed
Patients
(n=190)

Patients Dispensed
Rx products
(n=174)

Patients Dispensed
OTC Products
(n=171)

19

HCPs are directionally more likely to dispense to

patients without prescription insurance coverage
Patients With Insurance Covering Rx

% HCPs Patients With Insurance

Covering Rx Medication

100%

(Among Dispensers)

54%
47%

45%

0%
General Non-Dispensed
Patients
(n=190)

Patients Dispensed
Rx products
(n=174)

Patients Dispensed
OTC Products
(n=171)

20

Dispensers more likely than non-dispensers

to perceive patient benefits to dispensing
Patient Factors
Dispensers (n=190)

Non-Dispensers (n=189)

100%

0%

Strongly Disagree (1-3)

My patients are pleased that I dispense medications to them.

* 25%

My patients are willing to pay a premium for the convenience

of receiving their medication at my practice, rather than at a
pharmacy.

50% *
21%

5%
* 31%

Dispensing by physicians in my specialty improves patient

safety.

My patients request that I dispense medication to them.

63% *
7%

4%

Dispensing by physicians in my specialty reduces the cost of

healthcare to my patients.

Dispensing by physicians in my specialty reduces the cost of

healthcare to society.

3%

* 40%

Dispensing by physicians in my specialty improves patient

adherence.

100%

Strongly Agree (8-10)

47% *
16%
45% *

6%
14%

* 28%

45% *

7%
* 35%
* 61%

16%
32% *

14%
8%
21%

* 44%

23% *
10%

21

Non-dispensers have greater appreciation

for the pharmacist role
Healthcare Providers and Pharmacists
Dispensers (n=190)

Non-Dispensers (n=189)

100%

0%

Strongly Disagree (1-3)

51% *

6%

Dispensing medications to my patients makes me

feel I provide a higher level of care.

* 38%

Physicians in my specialty should receive training

in how to dispense medications

15%

18%

35%

* 33%

28%
e

It is important for pharmacists to double check my

work.

Pharmacists make too many medication errors

when they dispense medications.

100%

Strongly Agree (8-10)

41%

20%
29% *

31%

49%
* 70%

10% *
8%

22

Many procedures perceived as not highly

important and burdensome
Among Dispensers
(n=190)

Perceived Importance
of Procedures
0%

Perceived Burden
of Procedures
100% 0% Highly Burdensome (8-10)

Highly Important (8-10)

Patient Counseling
for Dispensed Medications

78%

13%

Proper Drug Storage

(i.e., lighting, temperature, security)

78%

13%

Maintaining Prescription and

Drug Record Keeping

72%

System Verification of Product before

Dispensing (i.e., double check)

70%

Drug Stock Labeling and

Inventory Control

64%
58%

Medication Profile System/

Medication Dispensing System

US Pharmacopeia Standard Sterile

Compounding Facility

27%
16%
24%
e

Prescription Labeling

Generic Substitution

100%

24%

54%
38%
32%

33%
18%
48%

23

More than a quarter intend to dispense

more in the next 2 years
Future Dispensing Behavior
(% Dispensers)
100%

Dispensing is getting to be an issue with proper

record keeping---too much time involved.
11%

I will dispense to
fewer patients in the
next two years.

The time and effort is burdensome to our busy

practice.
It is not financially worth my time.

I will dispense to the

same proportion of
patients in the next
two years.
I will dispense to
more patients in the
next two years.

61%
It is more convenient for the patients.
As more medications become available for me to
e
dispense, I will take advantage of the opportunity.
28%

0%

People like the service as it saves time and money.

They are spreading the word to others.

Dispensers
(n=190)

24

More than 1-in-5 non-dispensers are likely

to dispense in the next 2 years
Likelihood of Dispensing
in the Future
Definitely will

100%

(% Non-Dispensers)
1%
4%
22%

It makes it very convenient for the patient and this

way, I will know that they are getting the correct OTC
and RX medication.

17%

I believe dispensing may allow patients to start

using the medication sooner and may provide some
financial benefit to the practice.

39%

I believe there needs to continue to be a check and

balance in the healthcare system I think patient
safety is far more important that convenience.

17%
Very likely to
Somewhat likely to
Somewhat unlikely to

Very unlikely to
Definitely will not

22%

0%
Non-Dispensers
(n=189)

It is not practical to stock all of the possible

medications...You may be inclined to use a specific
medication rather than the appropriate medication.
The benefit to my patients does not outweigh the
extra work involved for my staff.

25

CONSUMER PERCEPTIONS OF THE DISPENSING OF

PRESCRIPTION AND OTC PRODUCTS BY HEALTHCARE
PROFESSIONALS
QUALITATIVE RESEARCH

NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

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RESPONDENTS CAME FROM ACROSS THE COUNTRY

West Region
211 (21%)

Midwest
Region
258 (26%)

South
Region
331 (33%)

Northeast
Region
199 (20%)

DEMOGRAPHIC INFORMATION
Total
(n=999)

Rx
Purchasers
(n=762)

OTC Only
Purchasers
(n=237)

46.6

46.7

46.3

Caucasian

82%

81%

85%

Black or African American

10%

10%

8%

Asian or Pacific Islander

7%

7%

5%

Native American or Alaskan

Native

1%

1%

1%

Other Race

2%

2%

3%

7%

7%

8%

Consumer Age (mean)

Racial Background (%)

Hispanic Background (%)

Age 65 y.o.: 15.5%,

Without private insurance: 42.5%

Two-thirds of Rx purchases are from a

local pharmacy or supermarket
Where Rx Products are Purchased
(% Rx medications purchased in last 12 months )

100%
Local Pharmacy
Local Supermarket /
Convenience Store

50%

Mail Order

17%
Physician s Office
or Clinic

16%

Other

0%

14%
3%
Total
(n=762)

14% of Rx purchases
are directly from the
Healthcare
Practitioner

29

One quarter believe Rx products cost less

when purchased from a Healthcare Practitioner
Perceived Cost of
Rx Products from a Healthcare Practitioner
(% Rx Purchasers)

100%
19%
The cost is higher than
in a pharmacy

The cost is about the

same as in a pharmacy

58%
e

The cost is lower than in

a pharmacy

23%
0%
Total
(n=762)

30

Most likely to purchase Rx from a General

Practitioner or Internal Medicine Physician;
around three times per year.
Purchased Rx from a Given
Health Care Practitioner
0%

Total (n=762)

100%

General Practitioner / Family Practitioner

75%
50%

Internal Medicine / Internist

Mean Times
Rx Purchased
3.02
3.03

Mental Health Professional

37%

4.02

Dermatologist

36%

2.00

Obstetrician / Gynecologist
Cardiologist
Nurse / Nurse Practitioner
Oncologist
Other

3.42

28%

3.21

25%

2.87

23%

2.50

18%
49%

2.99

31

Pain, antibiotic, and heart medications most

likely to be purchased from Healthcare Practitioners
Rx Products Purchased
0%

(% Rx Purchasers, n=762)

Pain Medications

20%

(Ibuprofen or similar, Codeine or similar, Celebrex, or Skeletal Muscle Relaxants)

Antibiotics or Antiviral Medication

18%

Heart Medications

14%

(Blood Pressure, Heart Disease, Heart Rhythm, or Water Pills)

Central Nervous System

(Headache, Depression, Anxiety, Anti-Parkinson s, Anti-seizure, Medications for Sleep)

Drugs for the Stomach or Intestines

100%

12%
8%

(Antacids, Digestants, Anti-ulcer Medication)

Eye, Ear, Nose or Throat Medications

8%

Contraceptives

5%

Medications for the Lungs

4%

Blood Thinners

3%

Other Prescription Medication

8%

Other medications varied, but most

common mentions were diabetes
medications, hormone replacement
therapies and dermatological agents

32

Three-quarters of Rx purchases from

Healthcare Professionals are routine purchases
Proportion of Purchased Rx Products that were
Emergency vs. Routine Refill:
(% of Rx Purchasers, n=762)

Emergency Refill (i.e., when you ran

out of a medication and were unable
to get to a pharmacy)

24%

76%
Routine Purchase
e

33

10-20% of HealthCare Provider dispensed

Rx s are missing important labeling information
Included on Rx Product Label
% Answering Yes
(n=762)

0%

100%

Name of the prescription product

93%

The directions for use

92%

Your name

86%

The fill date of the prescription or its last

dispensing date

85%

The name of the prescriber

85%

Any cautionary statements about the

prescription product
The prescription number assigned by the
practitioner
The name, address, and telephone number
of the practitioner

83%
79%
76%

34

At least a quarter do not get adequate

counseling and information at time of sale
Often/Always Reviewed by
Healthcare Practitioner
0%

%Often/Always
(n=762)

100%

How often to take the medication

77%

The name of the medication

76%

How to take the medication (e.g., with food,

certain times of the day, etc.) What are the
serious side effects to watch for
Why you were being prescribed and sold
the medication
What side effects the medication might
have
What to do in the case of any serious side
effect occurring

71%
65%

61%
59%

35

Primary Care Physician or pharmacist

consulted for adverse drug reaction from
pharmacist dispensed Rx
Occurrence of Serious Side Effect on Rx
from Pharmacist:
(% of Rx purchasers, n=762)

No

Yes

Medical Professional First

Consulted
(% Experiencing a serious side effect, n=53)

0%

100%
42%

My Primary Care Physician

93%

7%

The pharmacist who sold you

the prescription

30%

An urgent care /
Emergency room physician
Another Pharmacist
Another Healthcare
Professional

15%

11%
2%

36

Dispensing Healthcare Professional more

likely to be consulted for dispensed Rx
adverse drug reaction
Occurrence of Serious Side Effect on Rx
from Healthcare Practitioner:
(% of Rx purchasers, n=762)

No

Yes

Medical Professional First

Consulted
(% Experiencing a serious side effect, n=53)

0%

100%

The healthcare professional

who sold you the prescription

93%

64%

7%

28%

A pharmacist

e
An urgent care /
Emergency room physician
Another healthcare
Professional

6%

9%

2%

37

It appears some purchase from Healthcare

Practitioners even if they strongly disagree
with purported benefits
Patient Factors
Rx Purchasers (n=762)

OTC Only Purchasers (n=237)

100%

0%

Strongly Disagree (1-3)

I am pleased that my physician / nurse sells me the medication directly.

Dispensing by a healthcare professional other than a pharmacist improves

how likely I am to comply with the instructions for taking the medication
(number of doses, when to take it, etc.)

13%
17%

100%

Strongly Agree (8-10)

44%
37%

22%
27%

36%
29%

Dispensing by a healthcare professional other than a pharmacist improves

how safe it is for me to take the medication.

19%
22%

36%
31%

Dispensing by a healthcare professional other than a pharmacist reduces

the cost of my healthcare.

20%
24%

35% *
25%

I am willing to pay a premium for the convenience of receiving my

medication at the physician s office or clinic, rather than at a pharmacy.

I request that my physician / nurse sell me the medication directly.

37%
39%

26%*
17%

36%
42%

25%*
18%

38

SUMMARY OF RESEARCH SERIES OF HEALTHCARE PRACTITIONER

.2012MARK MUNGER, PHARM.D. ALL RIGHTS RESERVED

Dispensing of legend and OTC medications by healthcare practitioners is firmly entrenched in the U.S. healthcare
marketplace.
The practice is driven by practitioner perceptions of better convenience (consumer agreement) and medication adherence
with healthcare cost reductions.
Healthcare practitioner dispensing will continue to expand with greater consumer knowledge of the practice.
There appears to be no direct signal of adverse safety from healthcare practitioner dispensing.
Collaborative discussions among all healthcare providers must occur towards provision of a consistent dispensing practice
model for optimal consumer safety.
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

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SELF-ASSESSMENT QUESTIONS
Physician dispensing in the United
States is:

Physicians perceive drug

dispensing as:

A. Rare

A. Reducing the drug cost to my patients

B. Practiced daily or weekly

B. Reducing the cost of healthcare

C. Commonplace across all practice

settings

C. Improving drug adherence

D. All of the above

D. Under the direction of the Board of

Pharmacy in most states
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

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SELF-ASSESSMENT QUESTIONS
Physician perception of the highest
burden of pharmacy practice rules on
dispensing practice is:
A. Labeling the prescription bottle
B.

Keeping a medication profile system

C. Drug stock labeling and inventory

control
D. Maintaining prescription and drug
record keeping
NABP 110th Annual Meeting 05/20/14 Phoenix, AZ Munger MA et al. Pharmacotherapy 2014

41