The day pharmacists have talked about for two years has arrived, and the practice changes mandated by the Omnibus Budget Reconciliation Act of 1990 are now a fact of life. How the federal regulations will play out behind the counter depends, to a certain extent, on the nitty-gritty rules adopted by individual states.
Congress sketched the outlines of patient counseling and drug use review for Medicaid patients. It was left up to the states to fill in the details. To find out how OBRA '90 was being implemented, the University of Texas at Austin College of Pharmacy researched the regulations of all 50 states. Its findings are included in the summary chart at the right. At the various state agencies contacted, many were able to supply only copies of proposed regulations or draft legislation. The information in the table may reflect an assessment of draft language, not the final implemented regulation or law in that state. (For a discussion of how the counseling regulations will affect pharmacists under OBRA, see the continuing education article on page 108.)
In addition, some states had other reasons for being unable to provide a copy of either proposed or final rules. These states are identified in the comments section of the summary chart.
Although the chart gives an idea of how the various states have opted to implement OBRA '90, the table reflects the authors' interpretations of the rules and laws that were provided and should not in any way be considered the final authority for determination of how these rules or laws will be enforced in the respective states. It is recommended that each pharmacist consult his or her respective state board of pharmacy to determine the final rules or compliance requirements in any state.
When the states began to grappIe with OBRA '90, many questions had to be answered about the procedures for implementing patient counseling and DUR. For example, 22 states decided that only the pharmacist could make the offer to counsel, but 14 states allow the R.Ph. to designate someone else to make the offer. Eight states had not addressed the question.
On the question of whether the regulations apply to refills, 16 states decided they do, while 14 think not; eight leave it up to the pharmacist's judgment. Sixteen states wrote regulations to cover mail-order pharmacy, but 28 did not.
Three states--Connecticut, Maryland, and New Hampshire--apply the OBRA '90 standards only to Medicaid patients; in Missouri, rules on patient counseling are restricted to Medicaid patients, but DUR applies to all patients. The states that opted to address only Medicaid patients may find that chaos will erupt under state law malpractice claims where pharmacists have assessed each patient's payment source before determining the type and level of care to provide. …