Sitting in an exam room at Kern Medical Center's outpatient clinic, Jeff Jolliff examined a half-dozen bottles of prescription medications.
Dressed in a long, white lab coat, Jolliff chatted with Isidora Ortiz, a diabetic and the prescriptions' recipient, about her daily blood pressure and blood sugar levels. It looked like a typical doctor's visit except for one detail: the title embroidered above Jolliff's jacket pocket read "Pharm.D.," not "M.D."
Jolliff is a pharmacist and at the diabetic clinic, he helps patients by closely monitoring their medication and teaching them how to manage their condition.
"It's not a typical approach but it's in an effort to really increase access to care," Jolliff said of the program, which is about four years old.
With millions more Californians expected to be eligible for health insurance next year, when major provisions of the Affordable Health Care Act start to take effect, Jolliff hopes that a bill currently in the state Senate will recognize pharmacists as health care providers and open the doors for reimbursement for services.
Currently, the diabetes clinic mostly sees patients on the Kern Medical Center Health Plan, a managed care plan. But Lisa Ohlfest, KMC's administrator of clinics and physicians, said other commercial insurances and public programs, such as Medi-Cal and Medicare, won't reimburse for the services.
The pharmacy practice bill is one of a handful of measures that aim to allow non-physician medical workers, including nurse practitioners and optometrists, to provide more services for patients.
The bills' supporters said the legislation would allow health care providers to practice to their full potential and help meet the increasing demands on the health care system.
One bill would allow nurse practitioners to approve treatment plans for patients on home health services without having to secure a physician's approval. Another would allow optometrists to prescribe more kinds of drugs and order more tests. The bill related to pharmacists would allow them to prescribe certain medications, including hormonal birth control and smoking-cessation drugs.
"I think what (the bill is) going to offer is entry-level primary care to more patients," said Sen. Ed Hernandez, D-West Covina, an optometrist who introduced the bills regarding nurse practitioners, pharmacists and optometrists.
But the measures are hotly contested by the California Medical Association, the trade group that represents physicians. Representatives from the group have said the bills go too far in what they allow these professions to do without a physician's supervision. They also said the bills could fragment the health care delivery system and distract from the goal of having a "medical home" for every patient.
Clinica Sierra Vista CEO Steve Schilling said he sees "a lot of room for conflict and contradiction and misdiagnosis and confusion" for patients.
"I don't think I support these bills, and our state primary care association does not support these bills," he said.
HOW TO MEET THE NEED
Kern County's ratio of primary care physicians to population is 2,021 to 1, almost half the national benchmark, according to the Robert Wood Johnson Foundation's 2013 annual county health rankings.
Kern isn't alone in its primary care shortage. According to a 2009 report by the California HealthCare Foundation, only 16 of California's 58 counties had enough primary care physicians. The study also found that 34 percent of active physicians were working in primary care.
The shortage is exacerbated by a physician population that is reaching retirement age, said Jolliff, the KMC pharmacist.
"The doctors are fighting (the bills) but the reality is, who's going to take care of these patients if we don't have the ability to, to the fullest extent of the law?" said Blanche Glazier, a local nurse practitioner. "The demand for providers is going to be so great that we're going to have to spread the wealth around and have other providers pick up the slack."
But public health officials said they're not sure the bills provide the right solution to the primary care shortage.
Dr. Claudia Jonah, Kern County's public health officer, said she was particularly concerned about optometrists being able to order tests and treat conditions outside of eye diseases.
"I think that actually undermines that whole idea of trying to get a medical home for that patient," Jonah said.
Molly Weedn, spokeswoman for the California Medical Association, said that while there should be discussion about how to best use professionals to the level of their training, it's hard to start that conversation when the bills would allow practitioners to work "so far beyond what folks have been trained to do."
The medical association, in turn, is promoting a stack of bills to shore up the physician workforce, including measures to stimulate training and encourage doctors to practice in underserved areas of the state.
Weedn said another danger of the bills to expand non-physician practices is that they could set up a two-tiered medical system based on where people live. Just because someone lives in an underserved area doesn't mean he or she should only have access to a nurse practitioner, she said.
But others countered that the health care system is already bifurcated, with the uninsured and those on Medi-Cal having less access to care and specialists. Brent Fulton, assistant adjunct professor of health economics and policy at the UC Berkeley School of Public Health, said that while a doctor might be everyone's first choice, seeing a provider with less training may be better than not receiving care at all or having to travel a long way to get it.
"If the alternative is no access, then these bills make a lot of sense," Fulton said.
Supporters of the bill said they have the proof that these non-physicians can offer good quality of care. One review of 26 studies found that treatment and prescribing practices were consistent between physicians and nurse practitioners, a brief from the Health Affairs' journal noted. Jon Roth, CEO of the California Pharmacists Association, pointed to a report to the U.S. surgeon general that showed positive outcomes from expanded pharmacy practice models.
SEEKING GOOD OUTCOMES
At the KMC clinic, Jolliff and Ohlfest said outcomes have been very positive.
From January 2005 through March 2011, patients seen at the pharmacist-managed clinic had a 75 percent decrease in hospitalizations and emergency department visits related to diabetes complications, according to the clinic's own data.
Jolliff said pharmacists have a lot to offer.
"When you think about having a four-year degree, a doctorate degree in medications and medication management, (pharmacists are) very, very good at selecting the right medications for the patient to decrease adverse drug reactions -- which could be extremely costly -- and also (at) finding the cost-effective medications," he said.
But doctors still play a key role in the clinic, and Ohlfest and Jolliff said they can't imagine it any other way.
"The physician's still the quarterback," Jolliff said. "We want to help them by being able to take on these nuances of intricate details of drug therapy."
Dr. Alan Ragland, one of the physicians who works with the clinic's pharmacists and patients, said pharmacists are great resource to patients and doctors but that they are part of a team, not the team leader.
"I personally believe that our diabetic care and the control of our patient care is much better in our population because they have the ability to see someone who knows medications and can adjust them on a much more frequent interval," he said.
Ragland said allowing pharmacists to be defined as health care providers "would be a good thing, like all things that we are doing now to assist physicians and address the shortage of physicians."
But he added that doctors should be the ones to make the initial evaluation for patients and then determine if another health professional can address their issue from there.