Statewide Shifts to Pharmacy Standard of Care | Kate Gainer, PharmD, CEO , Iowa Pharmacists Assoc.

Speech to text errors have not been corrected.

Mike Koelzer: Kate, for those who haven't come across you online introduce yourself to us.

Kate Gainer: My name is Kate Gainer. I'm the Executive Vice President and CEO of the Iowa Pharmacy Association. Representing over 2, 500 members including pharmacists from all practice settings, pharmacy owners, pharmacy technicians, and student pharmacists.

I've been in my position with IPA for just over 12 years. 

Mike Koelzer: [00:01:00] Kate, you mentioned all. Is that a struggle these days as you start seeing some people say, we don't like the PBMs and that kind of stuff. that a struggle to represent everybody?

Cause I know that's important. It can be a challenge as one state pharmacy association to provide value, services, resources that are relevant to all of those pharmacists.

Kate Gainer: To me, while there may be challenges in representing a large group the benefits are bringing together a diverse representation within the same profession. And while it's important to have Those with a similar niche or practice background or geographical region or employment arrangement. So that you can share challenges and struggles.

We strengthen the position of IPA [00:02:00] by having different opinions around the table. We all learn more at the end of the day.

Mike Koelzer: And I think the value too, is you see now with social media, the different camps, and then they just go back to their camps in the evening and get more embedded in that camp. And I think the value of some of the state associations and counties and so on, is that you're physically there with somebody, you might be at the same table as them or at the same convention hall or something.

 All the technology is good, but it's important to know people from different camps. And I guess you can throw that in there, however you want to with religion or politics or whatever. But I think that's where some of the damage in society is today is that everybody's just doing their own thing.

And you didn't, you don't. I remember 15, 20 years ago, we'd get together with seven or eight of the business owners around the area and just have breakfast and shoot the breeze and things like that. And [00:03:00] With technology, you don't necessarily need that anymore because you can email out problems and things like that, but something's missing, just not being in the same room with people.

And it's efficient, but maybe not always as effective as it should be.

Kate Gainer: Yeah, you talked about Mike being president of your county association earlier in your career. Is your local county association still active? Do you know, do they still convene monthly or host meetings? Yeah.

Mike Koelzer: We're active and I should do better. . I might've been the president of it back in I don't know, late nineties or something like that, which seems like yesterday, but of course it's 20 some years ago, but it was always a struggle to engage early graduates with the later people. And I've got to tell you, Kay, I know you're an optimist, but in my head, I bitch a little bit about [00:04:00] things sometimes. And one of the things I kind of thought, and this is terrible because I don't want to put this on anybody, but. So involved with the association, but then as soon as we kind of got off the board, we weren't put out to pasture, but I think the current group could have reached out a little bit more and held on to our generation. Why am I griping about that? Because I could have done the same thing. I could have done a better job of keeping up, but it just wasn't. I think it kind of went like that, almost like in generations or half generations. And I, we all could have done better. Me number one could have done better, but I'm not as, I'm not as involved as I probably thought I would have been once I got off the board.

to joke about some of the old farts 

Like at our summer meetings at one of the guys' houses.

Mike Koelzer: We had this guy that would, he'd fall asleep on the back porch and he'd [00:05:00] have his job stockings on up to his knees with his shorts on things like that. We always joked about the old farts and now maybe I'm just self conscious.

Maybe I dug my own grave. And it's coming back to haunt me the way I treated some of the old people. It was always with utmost respect. Besides the time that we were making little jokes about them, 

Kate Gainer: one of the things I like to do is build those generational bridges. I think we have so much to learn from pharmacists that have been in the profession for decades longer than us. And at the same time, so much to learn from the young pharmacists that are coming out with a different frame of mind, sort of different way we see the world, and you could just use technology as one example.

And,

 There may be some of the older generation that might not embrace technology the same way. And. [00:06:00] There might be some of the younger generation that might think everything can be done via technology. And I think if you bring those conversations together, you can find that high tech and high touch can live in the same world as a healthcare provider and then start to have this magical conversation about it.

So let me turn the question back to you, Mike, as a self proclaimed ornery old guy, Let's peel it back a little bit. So, say there was an event in your county of pharmacists getting together, not for continuing education, not for advocacy in the political arena, but for, picking up trash to keep the highway clean, or for packing meals for, , underserved areas or something that was not professionally pharmacy related, but it was with a group of pharmacists.

And it was to build that shared experience. It was to create [00:07:00] connections. What would get you there?

Mike Koelzer: Kate, as we're talking here and I'm kind of thinking through this, I think one thing that might get me there, and this is a tall order, I understand that, but I'm the thought of at least pretending like you want the wisdom from the older people it might be separate invitations.

 When I was on the board, we just sent out one invitation, it was just a Fax or email or something. But if you have those different groups, one thing I'm thinking now would be to have three or four different invitations. So in your email database, you take. Let's say you got 400 names, you take the first hundred and you say, Hey, this is a great chance to do this as a young person. And then the middle people it's a, Hey, this is a good way to merge this and that. And then for the old farts it's, Hey we know you've been through it. We appreciate, you know, we, we think we can gain something from your wisdom.

You don't have to do much [00:08:00] except 

 I need some donuts.

Mike Koelzer: kate, 

I'm reading about the Iowa five, five, five bill. That's kind of an exciting thing for you guys right now. Right.

Kate Gainer: Yeah, that was our top legislative priority in the state. Bill that passed in 2024 to modernize Iowa's Pharmacy Practice Act.

Mike Koelzer: Did that do something, progressive or just kind of got things caught up?

Kate Gainer: I would say it did something progressive, but not something many pharmacists have talked about, or even pharmacy associations. It's not, quote, provider status or payment for services.

Mike Koelzer: Yeah.

Kate Gainer: But another way of looking at it is: It was like we swung for the fences, if you will, because we're not just looking to add one new service or one new scope expansion [00:09:00] or a limited payment authority for x, y, or z service.

The Practice Act update in Iowa makes Iowa the third state in the country following Idaho and Alaska. to move pharmacy practice to a standard of care framework. So a standard of care framework also aligns pharmacists with other healthcare professionals, the way physicians, nurses, dentists, and others are regulated.

Pharmacists have been regulated in a very bright line manner. If you look at pharmacy rules or state practice acts, things are spelled out in a very black and white manner. Oftentimes including lists of what can and can't be done by a pharmacist. or what can and can't be done by a pharmacy [00:10:00] technician, which is inefficient for practice to keep up because anytime there's a clinical guideline change or new technology is introduced or education standards are updated or scope can expand, it takes the pharmacy profession years, if not decades, to get caught up to that change in technology, practice, clinical guidelines, education standards.

Whereas a standard of care framework allows more elasticity, if you will, for pharmacists to practice at the top of their training and experience. And it's not one size fits all. written in a bright line way of, these are the exact vaccines that a pharmacist can give, or these are the vaccines and ages that a pharmacist cannot give.[00:11:00] 

But rather, the standard of care framework says, is the act prohibited by law or rule anywhere else in this state? Question number one. Question two, does the provider, does the pharmacist have the training? experience and education necessary to provide this act? And question three, would another reasonable pharmacist with the same training, experience, and education provide the same act?

So when something were to come before the Board of Pharmacy in the state of Iowa, A complaint, for example, instead of pointing to Iowa Administrative Code 657, Chapter 14,

Mike Koelzer: Right.

Kate Gainer: to sub bullet B, I'm just, I don't know what that is,

[00:12:00] it doesn't say the pharmacist may or shall do X, Y, and Z, and this pharmacist who had a complaint brought against them was in violation or not in violation.

It would take the board of pharmacy, likely with testimony from a peer or panel of peers, to say this pharmacist was acting within the standard of care based on their training, their experience, and education, and then make the decision of whether or not that complaint was founded. So it's not black and white, which makes pharmacists.

a little uncomfortable,

Mike Koelzer: don't like but it does

Kate Gainer: provide like you said, is this innovative? Idaho passed this language five years ago. Alaska just passed the standard of care framework language earlier in 2024, and I do think [00:13:00] this will be The direction that we'll see other states pursue to position pharmacists to provide the care that their patients need.

Mike Koelzer: So it's a rolling law. It goes with the times it goes with the training. It goes with what everybody else is doing. It speeds things up. And I suppose if you don't have this law and you have it the way things were, you might have some renegade that's trying to pick things apart by loopholes in the law and all these games. But with this system, it's like the whole profession can move forward, hopefully forward without the onerous task of, Going back to the legislator every time

to do something like that, it's a whole shift of the attitude, I guess, of the whole profession.

 people don't have to babysit us because we

all care as much as the next person does.

Kate Gainer: There's a great bar graph that I've seen Jen Adams, [00:14:00] who's at Idaho State University presenting on standard of care and standard of care in the framework of scope of practice. So, most states Pharmacists would say there's one scope of practice which is established by either the Board of Pharmacy Rules or Pharmacy Practice Act saying here's what a pharmacist can or can't do.

And imagine a bar graph with three heights, one very low, one in the middle, and one very high. And those are three pharmacists and the height of their bar represents their training and their experience. And then say there's a red line across the middle that is the exact height of the middle bar, pharmacist B.

And that line across is the state scope of practice. So if you're pharmacist B, you're able to practice with exactly the scope that matches your training and experience. [00:15:00] But if you're pharmacist C and your training and experience is much higher than what your state law allows you to do, you're overtrained and really hindered from providing patient care that matches your training, education, and experience.

But now if your pharmacist A, the first, the lowest bar on that graph, and your state scope allows you to do more than what your training and experience brings you up to, that's actually a public safety concern. Because you could, based on the black and white language in the law, do something you do not have the training, education, or experience to do.

In a standard of care framework, there's not just one line across the middle of the graph for the scope of practice. But that line goes up and down [00:16:00] to match each pharmacist training experience and education.

Mike Koelzer: So Kate, I can guess what kind of groups don't want this to happen. When Iowa put this through, was it just a practice in being steadfast and doing it, or were there groups against it? I'm going to figure out the AMA and different people like that.

Did you hear from all those sides? 

Kate Gainer: Well, a few points. This was about a five year effort in Iowa to modernize the Practice Act wholesale. So we didn't just go in to try to update one section. But we looked at the Practice Act in its entirety. And I would also say, At the same time, our governor had a significant effort underway to realign state government.

review all sections of the code and administrative code for efficiencies and to remove [00:17:00] redundancies, cut red tape and really bring alignment and efficiencies across state government. So we had some tailwinds there working with us. And so we had a lot of requests from the legislature and the executive branch.

But even prior to that, like I said, five years ago, IPA had convened a task force to look at modernizing our practice Act. The last time it was in wholesale, updated, and rewritten was in the 1980s. So we said, let's take a big swing at this and, Line by line, page by page, section by section, look at what needs to be modernized for pharmacy practice today.

After that task force convened we hosted roundtables and discussion sessions both in person and virtually across the state. We took a pause due to the pandemic when we had these efforts underway, [00:18:00] but then we resumed and actually introduced the bill in 2023. So, it took us two years for this to pass.

in the state legislature. And it was a big bill, so we expected it would take more than one year. We only had one group of registered lobbyists that were opposed to the bill. It wasn't organized medicine. Actually, our state medical society was neutral. They reviewed it in its entirety multiple times and were not opposed to the bill.

The one group that was registered in opposition was the anti vaccine group in our state, and that's because the bill did talk about vaccinations and pharmacists authority to give vaccinations.

Mike Koelzer: Interesting.

Kate Gainer: we weren't expanding that authority,

um, that group in Iowa does come out [00:19:00] loudly against any legislation that mentions vaccinations.

So we had many meetings with that group, spoke with them multiple times and their leadership, um, we had no votes on the bill. There were 10 legislators in the House out of 100 that voted no, and also a handful of our 50 senators, I don't recall the exact number, that voted no. But by and large, there was bipartisan support for the bill.

Now the bill will go into effect. There's no overnight changes that happen regarding how pharmacists are regulated. But the board of pharmacy is simultaneously updating its rules. In our administrative code. So just to give you a feel for our governor's executive [00:20:00] order with reducing red tape and agency efficiencies, our board of pharmacy is proposing that their current administrative code chapters, which include 43 chapters, will be reduced down to eight chapters.

So IPA saw a preview of that and we will be submitting comments. Of course, there's a public comment period and there will be a full rulemaking process where those rules are noticed and there's a comment period. But just for a preview, like the state of Iowa is moving in that direction. So our practice act priority really aligned with the state's movement.

Mike Koelzer: Was there any politician or someone that seemed pig headed in this, or did it seem to go as smoothly as you wanted it to go? And I'm talking emotionally.

Did anything really get to you with this? Because it's a big change.

Kate Gainer: If I had [00:21:00] some frustrations, my frustrations would be That as one profession, even a unified state pharmacy association. That there's only so much bandwidth to achieve the priorities that are important to our members.

And this legislative session, we had two other really big priorities, including a PBM bill, and including a request for a Medicaid appropriation to fund an increased dispensing fee. So we were juggling three very large priorities. And at the end of the session, House File 555 did pass. Was a priority of IPA.

Our PBM bill did not pass. Although our state's regulators, the insurance regulators that are enforcing PBM laws and the rules, their bill did pass. And we [00:22:00] received some of the appropriation that we were going after to fund the Medicaid fee increase. So. I think that's a difficult thing for a lot of pharmacists to understand.

One is that you can't get everything done legislatively that the profession would like to get done. And how do you prioritize, almost going back to the part of our conversation where there's going to be different opinions and different thoughts around what's most important. And it's not. Only the what's most important that a state association or any group that you know works on legislative advocacy has to evaluate, but it's also where there is a political pathway and what can we get done realistically in a legislative session?

So we have a team that advises IPA. Of course, we [00:23:00] have a legislative advisory committee made up of our members and pharmacists and technicians from across the state. But we also have contract lobbyists and lobbyists on our staff that are at the Capitol every day during session that have literally decades of experience in seeing how things work under the dome in the state of Iowa, at least, and each state pharmacy association.

brings in that expertise to understand how you navigate the pathways and the politics that influence where your policy priorities can fit in. So that is a reality, but It can be hard to accept that, I guess, and I've been in my position for, like I said, 12 years, so I do accept it, but it's still difficult to represent all of the members IPA [00:24:00] represents and understand that we may not be able to achieve everything that's most important to everyone.

Mike Koelzer: What becomes the bottleneck at that point? Like, let's say you have these three great ideas. I imagine you only get the ear of the politician so long. I imagine there's only so much money. I imagine if you bring three things, you might be watering all of them down a little bit. What becomes the bottleneck of saying, well, we didn't pass these three?

 I get it. But how would you describe that, that you can't do three versus one?

Kate Gainer: How would I describe that? 

Kate Gainer: Yeah. , every day when we host IPA's Pharmacy Day on the Hill and most states have an event like that where a hundred or hundreds of pharmacists and students come to the Capitol for grassroots advocacy and showing that the profession is loud and viable and is needed in communities [00:25:00] across the state.

And when we kick off In Iowa, our pharmacy day on the hill, we usually have a session that talks about the three Ps. So there's policy, there's process, and there's politics. And I would say in most recent years, and I'll just use in Iowa, our PBM bill, because that was really the heartbreaker that didn't pass because We had very strong bipartisan support for that bill.

But ultimately, it was politics. So we had some hurdles that we couldn't get over. It really wasn't about the policy. Like I said, we had bipartisan support for what was in that PBM bill, and it was a very focused PBM bill. If you ask 100 pharmacists, what ways do you want to see PBMs regulated?

You could probably include 20 different [00:26:00] elements that could go into a bill. But it was a very focused PBM bill with only three main sections. And we had bipartisan support, like I said, and the votes to get that bill passed. As an association, we worked that bill through the right legislative channels in both of our chambers in the House and the Senate, but it came down to politics, which I like to tell the story.

We had a pharmacist who served as a lobbyist for IPA for two years. We had him on contract to help us out when we were short staffed and he'd been super active in pharmacy, legislative advocacy. He had been on our legislative committee. He had been at Pharmacy Day on the Hill for 10 plus years. He had served on the board of pharmacy.

 He really knew pharmacy advocacy and understood all of these policies. And his first session, being a contract lobbyist for us, got [00:27:00] pulled into some meetings with legislative leadership behind closed doors to talk about what was going to happen that session. And he said to me, Kate, I went in there prepared to talk about the PBM bill.

Like, here's what it's gonna do, here's the cost considerations to take into account, here's what the opposition is saying, but here's the counterpoint. Like, I can fight this issue, and I'm on the right side of this policy. And he said, I never even got to talk about the policy. It was just about the caucuses and politics.

.

I don't even live it every day. Thankfully IPA has staff that lives that every day. And most pharmacists don't live that every day either. But I would say at least in Iowa, our experience, and I think most state pharmacy associations are really good at the policy and the process, and you can't always control the politics.

Mike Koelzer: You got personalities. I imagine [00:28:00] every vote one of those guys or gals do, someone's looking at it, and it seems that. Maybe this 555 passed because it took a while to convince somebody. And if you brought this one up too, they might not know which way to turn.

I mean, there's a lot of politics and probably. Psychology behind a lot of that. And you just don't know that's why they call it politically correct . You just don't know how it's going to bounce, I suppose. 

So that's kind of par for the course. No one really got under your skin with that one. Kate, I brought up the AMA If I'm the AMA devil's advocate, I'm thinking. Before you know it, pharmacists are all going to say, we can do this and they're going to change as a training to do this. And then they're going to look at this moving target. And before you know it pharmacists [00:29:00] are dispensing any medicine they want to. That's coming from the mind of me thinking I'm a physician. It seemed like there had to be some of that. Opposition. Does the bill calm the nerves of those people worrying about practice overlap and things like that?

Kate Gainer: It really didn't come up, Mike, to be honest. That wasn't. Wasn't part of this bill or the discussion in this bill. I know in other states Tennessee is a great example. Just last week in Tennessee, the governor signed a bill That in a very bright line way, meaning it's very specific, calls out nine categories of drugs that pharmacists can prescribe.

Self limiting or otherwise easily tested by point of care, which a pharmacist can prescribe. Or pharmacy technicians could do things like [00:30:00] test and treat for strep, influenza, COVID, pep and prep treatments for HIV, prophylaxis. In Tennessee, their state medical society registered in support of that bill.

Mike Koelzer: That's great.

Kate Gainer: And so. You keep calling me out for being an optimist, like it's a bad thing.

Mike Koelzer: Kate, here's what you have to get straight. I'm an old fart here sitting at my desk, just bitching and moaning about this stuff and you're leading a huge organization, you're in a better spot than I am, I'm just here to kind of. Piss and moan about those things.

Kate Gainer: Well, and to kind of pull in a few threads of things that we've talked about before, I think it's building bridges. So you've got Physicians that are coming out of med school that are trained in an interdisciplinary education way that expect pharmacists to be part of the care team.[00:31:00] 

Mike Koelzer: There you go. Those nine things, for example, there's no crossover on a lot of that stuff.

Kate Gainer: yeah, I mean, I know there have been recent numbers pulled out. I just Looked online and now new projections by the American Association of Medical Colleges say that our country will face a physician shortage in 2036 of up to 86, 000 physicians.

Mike Koelzer: There you

Kate Gainer: And I think the number for primary care physicians is one of the most stark in terms of physician shortages.

And so filling that primary care shortage void if we Have strong pharmacists and pharmacies in communities that really are the face of healthcare, the first access point into the healthcare system. Pharmacists can serve as a great help if we think about it through the lens of what does a community need, what are the health needs, the public health needs and not [00:32:00] necessarily that anyone's trying to steal turf, but we're trying to make our healthcare system as efficient and accessible for patients as it can be.

Mike Koelzer: Kate, when it comes to the association and the Iowa board, I imagine the board is like the Supreme Court or something that doesn't have an opinion or am I wrong on that? Do they have a strong opinion on how this goes with the associations or do they just kind of keep their mouth shut and wait for stuff to come down on high and then they figure out how it's going to be promulgated.

Kate Gainer: That's a great question. As I mentioned, part of our governor's proposal to realign state government, the Board of Pharmacy was part of that and impacted in a few ways. So our state Board of Pharmacy recently reduced [00:33:00] the number of pharmacists serving on the board. So we have one fewer pharmacist on the board than we did previously.

And for the first time, our state board of pharmacy has an executive director that is not dedicated to being only the Executive Director of the Board of Pharmacy, but they serve as the Executive Director for both Pharmacy and Nursing, and also a Bureau Chief within our state agency, which is now called the Department of Inspections, Appeals, and Licensing, DIAL.

So they're a Bureau Chief over the whole Monitoring Division, so that's, in Iowa it's called IMP3 impaired monitoring for pharmacy professionals and the monitoring programs that exist for nursing, for medicine, for dental is also oversaw by the same [00:34:00] individual who is the executive director of the board of pharmacy.

Mike Koelzer: Kate, when I was a kid, I'd get a wallet from JCPenney, it would have like this accordion thing you pull out. Do you remember those with the wallets?

You might be too young for that, remember it was an accordion and have like 10 pictures on this side and 10 on that side. And it would be in part of this thick wallet and When you're a kid, you don't have pictures like this. So you'd cut out pictures of Daniel Boone and you'd put it in there and you'd maybe take a picture from one of the new frames you have in your house and put it in there just to fill things up. It kind of sounds to me like in this situation, if people have plenty of time, you can think of all kinds of rules that you want to follow. It almost seems like they're cutting them back and saying, look, you got to focus here because not having a lonesome director.

People don't fill up the time to prove their Necessity for that job. It's like, folks, we're going to get this done with a lot less, which may be that there's less [00:35:00] to worry about cutting down from, so many pages down to eight pages, something like that. Is that part of it? Do you think just to say you don't have the luxury of that anymore?

So let's not do it.

Kate Gainer: You know, if you've seen one state Board of Pharmacy and state government agency structure, you've probably seen one state Board of Pharmacy and government agency structure, so

 It is an important knowledge point though that pharmacists should understand the structure of their state board of pharmacy.

And in most states, the association has a really good pulse on that. We meet with our board of pharmacy every month in Iowa. And we have that open dialogue and relationship. Sometimes, we'll jump on the phone every week if we need to. But a state association can really help understand, if you're a pharmacist, what the dynamics are in your state.

But in Iowa, for example, because all [00:36:00] of these changes are taking place, many pharmacists are wondering what it will feel like with this new state agency organization where the executive director of the Board of Pharmacy is not dedicated to only the Board of Pharmacy. So we're in a period of time where there's a lot of unknowns.

I like to see that as an opportunity. IPA can fill that void, answer those questions that many pharmacists have about where this is headed. One of my favorite quotes from a keynote speaker IPA had at a convention we hosted is, people don't fear change, although we like to say people fear change, people fear loss.

In a moment of change, being able to recognize what is someone [00:37:00] losing

And how can I fill that void? Or as an association, what resources or services or answers may a pharmacist need? For example, in the state of Iowa, undergoing a large reorganization of state agencies, the regulatory board for our profession, the Iowa Board of Pharmacy.

 IPA and our Iowa Board of Pharmacy have a very collaborative, transparent, open dialogue. And as IPA was working on our practice act task force leading up to what ultimately became House File 555, we requested input from

The Board of Pharmacy throughout that process and they also shared that they believed it aligned with our governor's executive order 10 that would [00:38:00] compel them to rewrite every chapter of the Board of Pharmacy rules.

So they did provide input to us throughout the process.

Mike Koelzer: And they don't necessarily go up themselves, but they're kind of going through you to

Kate Gainer: They, right, they weren't lobbying for the bill. They were just sharing IPs. We requested their feedback and input because they would ultimately be. Adopting rules and enforcing the practice act in the state. But under the new realignment, one positive, if you will because I just can't help myself, Mike.

Mike Koelzer: I love it. now you've got me always like thinking about it, like, oh, I can't help it. Because the Executive Director of the Board of Pharmacy has previous experience at the Board of Medicine, and she's also the Executive Director for the Board of Nursing, because pharmacy will now be regulated under the same standard of care framework as physicians, nurses, dentists, and other [00:39:00] healthcare practitioners, the realignment in our state actually serves pharmacists well because There's going to be efficiencies within the state agency.

Kate Gainer: The Board of Pharmacy is not going to be trying to do it alone. The staff is going to have experience working with these other health professions boards that already regulate in a standard of care framework.

Mike Koelzer: I have heard, and I'm not sure if this is true, I think I was griping about the new Michigan PBM law told me, I think, that this law is carried forth or is really part of the board of insurances for the state and not the board of pharmacy. And I thought, If that's true, that kind of explains the speed or lack thereof that I think this implementation is happening, [00:40:00] but a real gift.

 The more that you have, I think the director is in charge of these things, just to see the interplay of all this stuff together, because we're not in a vacuum, certainly the insurance and the healthcare is not in a vacuum, but nor are dentists and nurses and all that working together.

So assuming you've got a decent leader that's a lot of. I can see that having a separate director for all of those on the positive side, you'd like to think they're working together, but also people have their pet projects and things. And so to see that director directing more than one seems like a pretty cool thing.

Kate Gainer: I think it'll be helpful. Yeah. And there's optimism for implementing House File 555 and how that will interact with our state's new Board of Pharmacy chapters that will be implemented by the end of the year as [00:41:00] well. It's another way state associations can bring value and work every day for pharmacists or for the profession.

You mentioned in Michigan, the insurance regulators. So IPA has a call I believe every other week with our Iowa insurance division to talk about the PBM rules that they're enforcing and help connect them with pharmacists who are filing the complaints. how to help our members efficiently file complaints to the insurance division who has undertaken the enforcement and implementation of regulating PBMs in our state.

And that piece of it, like you said, maybe in Michigan following passage of a PBM bill can be an entirely new advocacy lift in and of [00:42:00] itself, right? So you might think, let's pass a bill. Okay, so there's a lot of work that goes into getting a piece of legislation passed. But then, Who's enforcing that legislation?

What regulatory agency is taking it on? So, in Iowa, we passed our state's first PBM bill . You want to take a guess what year you think it was?

Mike Koelzer: You passed the PBM bill and you mean when was the first bill before that?

Kate Gainer: When was the first PBM bill in the state of Iowa passed? Period. Well, question mark!

Mike Koelzer: question mark. Well, I know you guys are progressive PBMs in my mind started being a problem in the mid nineties. So. I could go on the progressive part and say mid nineties, or I could go really late and say like 2018. [00:43:00] I'm going to go with the early one.

Kate Gainer: Well, we're right in the middle. 

Mike Koelzer: All right. I said mid nineties. So that was, let's say that's 98 and 2018. This means it's going to be in the. 2008 range, something like that.

Kate Gainer: 2007 was the first year we passed a PBM bill in the state of Iowa. So, a few years after, Medicare Part D and pharmacy owners really were feeling the squeeze of PBM practices. Now, of course, state bills at that time weren't able to effectuate any actions of Part D plans or plan sponsors or PBMs in the Part D space.

But since that time, we've created a relationship with our state insurance commissioner, the staff that works at our state insurance, the Iowa Insurance Division. It also has a new name since our agency realignment. But we have [00:44:00] calls with that state agency every month or twice a month as well.

So this is the work of a state pharmacy association. Advocacy doesn't just mean legislative advocacy and having a policy passed into law, there's advocacy that happens even after that point, or oftentimes during that phase as well, we're working with the agency that's ultimately going to enforce and implement something like PBM regulation.

So that piece in some states takes almost more time than actually passing the bill through the legislature. 

We were fortunate in Iowa to have established those relationships, a decade plus ago, and have worked with the agency on PBM enforcement for many years.

Mike Koelzer: Well, and we talked earlier about the benefits of still meeting with [00:45:00] people and the associations in that. And when you say relationships, I'm sure there are actually some real relationships between Sue and Richard or whatever. I mean, there's actually people that know each other.

You're not just talking that the offices know each other, but there's probably some true relationships and that helps out. You can pick up, talk to someone on the phone and explain something or answer a question, things like that.

Kate Gainer: Absolutely, and we're fortunate in Iowa, but again, I could speak for my counterparts in nearly every other state but this is the work state pharmacy associations do. We're able to pick up the phone if it's someone in the governor's office or if it's someone at the board of pharmacy, if it's someone as I mentioned just now in our state insurance division on PBM issues, if it's the media because we want to get some public relations or press on a certain issue This is part of the advocacy work that a state pharmacy [00:46:00] association does.

 That's

One of the things I talk about a lot is advocacy, not only legislative advocacy. But advocacy is anytime you're having a conversation about the role of a pharmacist, the importance of pharmacy infrastructure and keeping pharmacies open to provide health care to the communities they serve.

That advocacy, it's not just to the 150 elected state legislators in a state. But it happens every day in big and small ways. 

Mike Koelzer: Well, Kate, golly. i'm going to say that a little bit of your optimism wore off on me with politics. I'm still going to gripe about everything, but it's good to see. And it truly is good information. It's so cliche, but certainly every voice does make a difference.

You got to let your voice be heard. We certainly appreciate your time and look forward to keeping in touch and seeing the great things that you're doing [00:47:00] for the state of Iowa. 

Kate Gainer: Well, Mike, thanks so much for the opportunity to be on your podcast. I found myself realizing maybe I am an optimist more than I even say that I am. But having a healthy dialogue and a healthy discourse, even asking you, what would get you to show up to a professional event is helpful to me.

So each of these conversations, I know I learn. Something, and I hope that everyone listening to this episode of your podcast can take away one thing they learned as well.

Mike Koelzer: Very good. Thank you, Kate.

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