AH025 - Empowering Pharmacists, with NASPA's Krystalyn Weaver, PharmD, JD

July 5, 2024

Capital Rx

In this episode of the Astonishing Healthcare podcast, Executive Vice President and CEO of the National Alliance of State Pharmacy Associations (NASPA), Krystalyn Weaver, PharmD, JD, joins Justin Venneri for a discussion about pharmacists and expanding their scope of practice. She shares her insights on the role pharmacists can play in the healthcare system and highlights several positive developments recently, including Iowa including Iowa changing the scope of practice to be a standard of care model and Tennessee passing a law that allows pharmacists to prescribe in a "slew of categories" without requiring additional regulations.

Additionally, Krystalyn shares her thoughts on the importance of making progress at the federal level to allow pharmacists to be reimbursed by Medicare (ECAPS), the AMA's stance against the expansion of pharmacists' responsibilities, how to relieve the pressure on the pharmacy business model, what some pharmacies are doing to diversify their businesses and succeed, and much more. Listen below or on Apple or Spotify!


Lightly edited for clarity.

[00:27] Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. I'm Justin Venneri, your host and Director of Communications at Capital Rx, and today I'm excited to have a guest with us that is somewhat unique in that she is the Executive Vice President and CEO of the National Alliance of State Pharmacy Associations, Krystalyn Weaver. Krystalyn, thanks for joining us today.

[00:47] Krystalyn Weaver, PharmD, JD: My pleasure. Thanks for having me.

[00:48] Justin Venneri: So, it'd be great if you could spend another minute just on your background and your role at NASPA.

[00:53] Krystalyn Weaver, PharmD, JD: Sure. I am a pharmacist and an attorney. Pharmacist first, always. I have spent most of my career in association management. I started at the American Pharmacists Association and then joined the NASPA team right after that, focusing on state policy across the country, looking at how pharmacy is regulated as a profession with a laser focus on scope of practice, which is a fun challenge to take -- tracking state policy, since there's such different approaches that each state has. But that painful work opened up a lot of doors for us at NASPA to assert ourselves as the source of truth for state policy information as it affects the profession of pharmacy.  

So, I really enjoyed that work. To kind of grow my expertise in the policy world, I decided to go to law school and left NASPA for a couple years for that, and also spent a couple years at a corporate law firm here in DC and found my way back just this January in this new role.  

So, a little bit about NASA might be helpful, too. We're the National Alliance of State Pharmacy Associations. Our core members are the state pharmacy associations across the country. Our members represent the whole breadth of pharmacy, whether that's in the community setting, in a hospital setting, and managed care. Our members represent all pharmacists in their state. They are the foremost experts on advocacy in their states and pharmacy policy specifically. And we also have a category of membership for associate members, which ranges across the pharmacy industry, from technology vendors to PBMs like yourself, to chain pharmacies, to manufacturers, other pharmacy associations. And that broad voice really allows us to bring stakeholders together to find common ground on state policy and work towards mutual beneficial solutions that we can advocate for in the states.

[02:45] Justin Venneri: And there's definitely a breadth there that makes a ton of sense to have a broad community that's working toward common goals. And we covered some of the intricacies of the licensure and other things with Heidi McKinnon, our Head of Compliance, in a recent episode (AH023 - Compliance Matters, with Heidi McKinnon, PharmD, CHC). So, with our network and with everything going on in and around the pharmacy community, we know you guys play an important role.  

And it's funny, we ended up in touch, originally, as a result of some LinkedIn activity, by a mutual connection on some content relating to what pharmacists can do to provide care to patients and consumers, healthcare consumers. I know there's a lot of people in our country and our industry paying attention to what pharmacists are being paid to do and can do -- in other words, whether PharmDs can practice at the top of their license or not. Can you explain what the most recent developments are on that front?

[03:34] Krystalyn Weaver, PharmD, JD: Yeah, of course. So, the greatest change, I think in the last, probably five, well, more like ten years, has been allowing pharmacists to prescribe. Pharmacists for many, many years, going back probably 45 years or so to Washington state was the first state to pass collaborative practice authority. And a collaborative practice agreement allows pharmacists to pair up with another practitioner, a prescriber, who then delegates to the pharmacist the authority to prescribe. So, they enter into a contractual agreement where the, most often, physician delegates their prescriptive authority to a pharmacist. You can then execute that authority, and it can be other things too, like ordering labs or other services, but most often we see prescriptive authority. So that's been going on for many, many, many years, that pharmacists are writing prescriptions. But the way that we're trained, through six to eight years of education, allows pharmacists to have the expertise to prescribe medications for a variety of conditions. I would say for any condition, frankly, that the pharmacist is up to date and clinically prepared to manage, we are the best positioned providers to select that therapy.  

Personally, I am not the best positioned one because I have not practiced in many years, so I would not do so. And so, practitioners have to, of course, in all professions, exude professional restraint and only provide services that they're trained for. But by and large, our practicing pharmacists are extremely capable of that medication management. And we're seeing a huge wave of states utilizing pharmacists to provide public health related services. So preventive care, nicotine replacement therapy to help patients to stop smoking, oral contraceptives. Now, with COVID and flu season coming up, test and treat services where the pharmacist can test for our condition and if the patient is positive for it, they can then prescribe the appropriate antiviral or antibiotic medication.  

And that evolution has really exploded in the last ten years, where it was just a few states -- well, the first state was California that passed a statewide protocol authority allowing pharmacists to prescribe pursuant to a statewide protocol. And that concept has exploded and evolved to now we have several states that allow pharmacists to prescribe for any condition that doesn't require a new, complex diagnosis. And so, I think that that will continue to evolve. We don't see the mainstream accessibility of that like we would like because of limitations on the business model. Not all insurers are covering those services, even though there's a huge, huge supply of data showing that it is effective, it is cost efficient, and patients like the accessibility. So, I think that that will grow as payers recognize those things and look to innovate their own practices to provide an adequate network. But that's the area where we really need to advocate for, moving forward.

[06:40] Justin Venneri: Okay. And I know, I think everyone knows that pharmacists were asked to do a ton more during the pandemic, of course, in the response to Covid-19. I feel like I've seen a lot of studies related to the inclusion of a pharmacist on care teams, whether it be with primary care or whether it's with, you know, other specialists focused on the management of chronic conditions. It seems like the data is always positive around that. Is that kind of what you're alluding to as more data mounts and you hope to see more progress in that area of what pharmacists can actually be paid to do?

[07:14] Krystalyn Weaver, PharmD, JD: Frankly, the data is huge. You know, ten years ago, we were continuing to build the case. I feel like we don't even need more data to show. It doesn't hurt, but we've got it. I mean, the proof is in the pudding and it's out there. It's more of getting policies changed, and we have gotten policies changed in a big way in many places. And it's just not all 50 states. It's not at a federal level. We're still working at that federal level, especially this year. We've got a bill in Congress, we call it ECAPS, that has an excessive number of co-sponsors, and we're anticipating a score from the Congressional Budget Office soon. And getting that foot in the door with Medicare would make strides, especially coming up on flu season, towards allowing patients to access pharmacist services. But we still have to have the infrastructure in place to make sure that pharmacists can get paid from all settings for the work that they do.

[08:11] Justin Venneri: And I know the American Medical association, the AMA's response that was kind of what led to our interaction on LinkedIn, and there's some confusion around the separation of duties or maybe perception of what's encroaching upon a doctor's or prescriber’s area. What are your thoughts on that? I think I know what they are, but I'd love to hear you explain it.

[08:32] Krystalyn Weaver, PharmD, JD: Yeah, the AMA's response is really disappointing, and frankly archaic, and very much just turf protectionism. The AMA is opposed to any scope of practice expansion for any healthcare providers that are not physicians. And taking that strong stance is really obstructionist for patients.  

We're living in a reality where there's an extreme physician shortage. I don't know about you, but it takes me some time to be able to get in to see a physician, and having the convenience of being able to see a pharmacist who is around the corner from my house really makes all the difference. I know for someone like me, as like a busy professional who has a toddler, life moves pretty fast. And when you need to get care, you need to get care quickly. And so, you know, these archaic policies just don't make a lot of sense. I don't think that it's something personal that the AMA has against pharmacy. They take these strong stances against every health profession, regardless of the training, regardless of the evidence. It's just a hammer approach to opposing everything that expands scope of practice.  

It's interesting because the AMA has this strong position, but what we see on the ground is that practicing doctors really appreciate team-based care. They appreciate the role that pharmacists play. They themselves understand that having quick access to care is important for themselves and their patients. They know that there's not enough physicians to provide care and that if we expand the pool of providers, we can only make things better and more effective. So, there's really a disconnect, I think, from AMA's policy position and what we see on the ground, which is strong support from our physician partners.

[10:20] Justin Venneri: I used to hear a lot of positive feedback doing research on different value-based care models, or advanced primary care models, that the addition of the expertise in medication adherence drug interactions, just as a complement to the physician skillset, was always appreciated. It seems like it's logical for things you mentioned earlier that are, as you said, you don't want to practice beyond your capabilities. But for the simple things that I think a lot of people can agree on, it makes a ton of sense.

[10:50] Krystalyn Weaver, PharmD, JD: Absolutely. And, you know, the capabilities of one provider vary widely from the capabilities of the next provider. And that's why we have a system in our country that manages liability in a way that is personalized through the court system that I don't think you want to get into here, but happy to another time, if that's helpful. But that individualized approach, it means that you have to provide a standard of care to all of your patients that is similar to a reasonable provider in your position.  

And so that means that if I'm not educated to manage your chronic condition, then I can't do that. I can't provide that care even though I'm licensed to do so, because I couldn't meet the standard of care to do that. And so that allows for broader laws than the least common denominator. We don't have to legislate to the worst pharmacist. I'll take that title because I don't practice anymore. You don't have to legislate to the Association Manager Advocacy Pharmacist. We can instead write policies that are for the best pharmacists, so that we're not holding anyone back. And that's what these scope expansions really do, is allow for the pharmacists who are on the cutting edge, that are well trained and well positioned to provide care or are able to get additional training to provide care and meet the needs of their communities. And it's really not about a turf issue. There's plenty of sick people to go around. So, from a business perspective, the AMA doesn't really need to worry, I don't think.

[12:19] Justin Venneri: And then we just have a couple more questions for you. We appreciate you sharing your thoughts with us. Are there a couple of states where you're monitoring things more closely because of recent activity moving in one direction or another?

[12:31] Krystalyn Weaver, PharmD, JD: Well, we've had some big wins this year. In Iowa, they changed their scope of practice to be a standard of care model that I was just alluding to that exists in our court system. But they articulated that in the Pharmacy Practice Act, saying that pharmacists practice to a standard of care similar to that of other healthcare providers and that pharmacists can prescribe for conditions that don't require a new diagnosis, that can be easily identified with a point of care test. And so, this is a really big win for pharmacy and for patient access to care in Iowa.  

Similarly, Tennessee passed a law that allows pharmacists to prescribe in a slew of categories without requiring additional regulations. So that law went into effect immediately and will allow pharmacists to innovate very quickly. So lots of changes happening across the country, but two great wins that are at the tip of my tongue, at least.

[13:26] Justin Venneri: That's excellent. Okay. One thing that I know is just a broader concern, and it's kind of a negative, and with Walgreens recent announcement, pharmacy deserts and pharmacist burnout and things along those lines -- it'd be great to hear your thoughts on if there are any potential solutions that you see or ways to make progress in expanding the access to pharmacies instead of kind of expanding the mileage to get to a pharmacy.

[13:52] Krystalyn Weaver, PharmD, JD: Absolutely. You know, the business model for pharmacy has been crunching for years. We have had a pinching of the reimbursement for drug products curve over the last 20 years, and it feels like it's reached an apex. And pharmacies just can't stay in business. And at the same time, we're asking pharmacists to provide these services that their communities need, but we don't have adequate reimbursement for those services. And so pharmacist burnout is very real.  

We have situations where hours are being cut, pharmacists are asked to do more with less help, and it's reaching a tipping point where we really have to get these policies in place that allow for the business model of pharmacy to make sense. And the way we do that is fair reimbursement. I know that your company is committed to that, and I hope that we can make progress on that front. But what I'm really focused on is ensuring that pharmacists get paid for what they really bring the value to, and that's the valuable services they provide.  

There's no other health profession that is expected to sustain their business on a commodity except for pharmacy. And we are expected to give away our services for free. And that makes no sense. We have to change the business model. And I think that that will fix those desert problems where pharmacies are closing, because they just can't survive in this market.

[15:14] Justin Venneri: Okay. And what are one or two things that you're seeing, whether through the state associations or just otherwise, that pharmacists can do or are being creative to succeed in the current environment?

[15:26] Krystalyn Weaver, PharmD, JD: Yeah, I think it's all about diversifying. I think the pharmacies that have innovated and have been able to develop these value-based payment arrangements with payers and have identified employers in their communities that want their employees to have access to valuable services that pharmacists provide, you'll see those kind of one off arrangements. But we need a broader solution. We need to pass the federal legislation for ECAPS, which will provide payment from Medicare for test and treat services, which will be really important for cold and flu season coming up.

Yeah, it's all about diversification. If we try to rely on the old model, we're not going to survive.

[16:03] Justin Venneri: Okay. And then, last question I ask everyone at the end. What's the most astonishing thing you've seen -- that you can share, of course -- as a non-practicing pharmacist or lawyer that you can share in and around healthcare, or healthcare services, or the discussion we're having today. Can you tell us a good quick story?

[16:20] Krystalyn Weaver, PharmD, JD: So the adjective astonishing is really interesting. I kind of hear that as like, almost like a negative thing. So, I mean, I think the most astonishing thing to me is that we really have this body of evidence that shows the value that pharmacists provide, but we haven't had the uptake that we really need. We have had huge changes, but not at the pace that I think we need it.  

But to share a good story, maybe that might not be astonishing, but is heartwarming -- I practiced just part time early in my career to stay in touch and because I liked it in a community pharmacy, in a grocery store chain. And little moments stick out to you. I remember helping a mom and a little girl who had a tummy ache finding an over-the-counter medication. And when they were getting ready to leave, the little girl just threw her hands up and gave me the biggest hug. And it was just the sweetest little moment that I'll never forget. And those kinds of moments are happening absolutely every single day in pharmacies across the country and just kind of highlights the close connection that pharmacists have to their community.  

We've had a lot of challenges in our industry, but we also have really great moments with our patients every day.

[17:32] Justin Venneri: And super quick at the end here. Thank you so much for spending the time with us today. If people would like to learn more about NASPA or get in touch with you, how should they go about doing that? And to the audience, we'll put some of the links to the studies and other content we referenced earlier in the show notes as well.

[17:48] Krystalyn Weaver, PharmD, JD: Yeah, please check us out on our website, www.naspa.us. But more importantly, if you're a practicing pharmacist, or someone in the pharmacy industry, please make sure you're connecting with your state pharmacy association.

[18:01] Justin Venneri: Krystalyn, thanks so much for joining us today.

[18:03] Krystalyn Weaver, PharmD, JD: Thank you.

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