Zach Rosko, PharmD, BCPS: Advocating for Pharmacy Regulatory Relief in Nevada

Kevin welcomes back Workflow Service's Director of Pharmacy Zach Rosko, PharmD, BCPS to discuss Nevada’s efforts to expand pharmacist clinical services and remove regulatory barriers that limit patient access, especially for Medicaid recipients. Their discussion explores how pharmacists’ advanced training supports safe, cost-effective care, and how legislative advocacy and relationship-building with lawmakers are driving momentum for future bills in upcoming sessions.

Learn how to be reimbursement-ready on day 1 for ECAPS at our knowledge hub for pharmacy industry professionals: https://www.workflowservices.com/ecaps

Transcript

Intro & Guest

SPEAKER_01 0:04

Hello, and welcome back to another episode of the ECAPSWatch podcast. I'm Kevin Hoolihan, your host and CEO at Workflow Services. Today I've got a repeat guest with me. Zach Roscoe from our team is back on with us. Zach is the director of pharmacy here at Workflow Services. And similar to our last episode where we talked with Shannon Breckendorf, Zach has been out in the field doing some of the good work on getting legislation progressed and advanced. Actually, it turns out we're not even able to get these episodes recorded and released as fast as things are going. Shannon, I think, has been back in the Colorado Capitol even since I talked to him. But Zach, you were out doing some of your own work, and I just wanted to have you back on and hear what's been going on with you. Tell us, share the share the stories and experience from what you were up to recently.

Nevada Advocacy

SPEAKER_00 0:54

Yeah, absolutely. Kevin, I'm also involved in the pharmacy community in Nevada. I'm presently serving as the president for the Nevada Pharmacy Alliance. And we have been the body representing, we're the APHA affiliate in the state, and we've been helping advance the profession in representing the needs of the pharmacy profession in Nevada. And during our last legislative session, we had two bills that were related to pharmacist clinical services, both a bill for payment mandates under the Medicaid program for pharmacist services and for an expansion bill. You can call it an expansion bill, but really it's a regulatory relief bill. It removes some of the regulatory impediments to pharmacists providing the care that we're trained to provide and can already provide in the state in different settings. But both of those bills were introduced in our last session. We had a lot of momentum with them. They were moving through the chambers of state legislature relatively well, but we just ran out of time in the last session. So we're in an interim session right now. We're one of four states that remain on a biennial legislative session schedule. So this is our interim year where we have standing committee meetings, but we do not actually have legislation running. And we were asked to come and present on these topics because there was momentum, there was interest. We were able to get legislators interested in seeing what pharmacists can provide in the state. And we were invited back to give a longer presentation to help educate the Health and Human Services Committee on what we're trying to do with these bills, what the impact for Nevadans would be, and what you might see as far as patient access if these were to move forward.

SPEAKER_01 2:43

Awesome. So who what what other kinds of folks were there with you? And tell me about some of the other things they were saying and other stories they told.

Panel Overview

SPEAKER_00 2:51

Yeah, so with this particular uh session, we had um I was part of a panel of three individuals. Uh another uh one of the pharmacists with me was an educator uh who works at Roseman University, our local college of pharmacy here in the state. And then the other individual worked uh in health system pharmacy. So he's uh a VP with uh pharmacy services with renowned health, and uh that's one of the large uh healthcare systems in the state, primarily in northern Nevada. And they were telling the you know impact stories of both what patients could see and do see when accessing pharmacy services, but also giving some background on the education and training of pharmacists. Um, some of the feedback in testimony individuals here, obviously in opposition, usually is that why are pharmacists delivering this? Is this safe? Is this effective? Are patients going to get quality care? And there's ample evidence to show this, and that's that's what we were there to provide. Give more of the background of pharmacist training and education pathways, show the similarity to other health professions. Uh we have a uh uh four-year graduate program, which uh confers a doctoral degree. Many pharmacists then advance to residency PGUI one through three, so generally one to two years, but some programs have three years of residency, and then there's board certifications and additional um specialties pharmacists can go into, which very much mimics the pathway of uh physicians. Obviously, the focus of training is different, but we have a very rigorous training and licensure program that allows pharmacists to develop specialty and expertise in patient care and have the qualifications that can ensure safe delivery. And we reviewed some of the evidence uh where there are studies that show both the cost impacts, patient access impacts, and safety of pharmacist delivery care.

SPEAKER_01 4:46

Awesome. You know, I love stories. Any stories that came out of a question that that someone that you were presenting to asked, or or something that somebody else um shared, or just any sort of interesting huh, it's a perspective that you weren't expecting, or that sticks with you or that you remember from the day.

Legislator Story

SPEAKER_00 5:05

I don't think it was at the actual session itself. It was in individual meetings with some of the uh legislators, and we've taken time to meet with a lot of them individually to hear their concerns or their um understanding of what these bills do and to provide some education. But I remember one uh legislator, specifically like the light kind of clicking in her eyes when she's like, So what you're talking about is removing barriers. So when my child, I you know, she was recalling a story when she just had to take her child to urgent care for a uh forget if it was uh it was an upper viral upper respiratory viral infection where she ended up, she wasn't sure if it was viral, bacterial, if they needed antibiotics or whatnot, and had to go to urgent care. And there was a prolonged wait because it was a very busy urgent care in her area. And she was like, Well, I still had to go to the pharmacy after that. And she's like, What you're saying is I could have gone to the pharmacy, received the service there from the pharmacist, and had my medication dispensed at the same time in just one stop, uh, if this goes through. And uh, we're able to tell her that's exactly what we're looking at here, providing another access point for especially these low acuity services in community pharmacies sometimes, and obviously there are other more complicated services that can be delivered in clinic-based settings in certain pharmacies that have the additional resources, but uh just seeing like hearing uh a legislator get that, oh, you know, this isn't just our you know uh constituents who are going to be impacted, but you know, this is my family as well. Yeah, starting to see what that could look like.

SPEAKER_01 6:47

When when you I mean, we love to hear that, right? This is not that's that's right, this is like for all of us. This is ever every, you know, the statistic, almost everybody lives within five miles of a pharmacy, and we're all um using them often and almost always a lot more than we see our doctors. Was there a message that you personally hoped to leave uh along with the folks you were presenting to? Like what was did you have a single point personally that this was this was what you wanted to resonate, especially having been called back to share more after some presumably effective earlier conversations that were happening in the state?

Key Message

SPEAKER_00 7:24

Yes. I I think the message that I really want to kind of hammer home and get across to legislators both in Nevada and across the country is that these services are not novel. When we're asking for these bills to go through, these services are being delivered in other states and often in the same state. What we are really looking for is a removal of regulatory barriers that are in place that limit patient access to them. For example, what we're looking to do with the two bills that were introduced last session, uh AB 186 and Senate Bill 118, it was to allow Medicaid recipients to access pharmacist services. So we can deliver a lot of these services in Nevada right now, but patients who receive Medicaid cannot have them paid for. They'd have to pay out of pocket or be referred to other providers. So we can deliver some of these services, but we cannot deliver them to Medicaid recipients. And then for many of the services we can deliver, our scope expansion bill, uh, for example, doesn't truly add any service that we can't already do under a collaborative practice agreement or under some other authority within the state. It just removes the barriers. A collaborative practice agreement is something that it's a document and it's administered differently in every state, but it's a pathway to grant scope or authorities or privileges to a pharmacist under a physician or another provider. But there's a collaborative liability there. Oftentimes prescriptions written by the pharmacist have to be under the name of the physician or CPA provider, and then they share that liability with the pharmacist. And that's doable. It works in many locations, but it also presents a barrier to quickly implementing this or implementing this, especially in rural areas or you know, areas where there aren't opportunities for pharmacists to build the relationship with the physician in a you know way where the physician is going to say, yes, I'll grant you prescriptive authority under my name. So

Scope Barriers

SPEAKER_00 9:29

this just allows pharmacists to do what they already do under their own authority without someone else sharing that liability with them. It doesn't necessarily mean that a pharmacist or a pharmacy couldn't have a physician partner who helps with quality assurance. But it just really the what we're looking to do is to remove the barriers to accessing pharmacist services. And patients are already getting these services across the country, just in a more limited scale.

SPEAKER_01 9:56

Yeah, it's a thing that I've pointed out a couple times on the podcast, but it's a crazy situation, it sounds like is the case today in Nevada, where two patients can walk into the pharmacy at the same time. And so you got a single pharmacist in a single state and a single store, and that pharmacist is able to provide services to the first patient, but not the second patient, just because of who the patient has covering their health insurance. Did I get that right? Like, is that basically what's going on?

SPEAKER_00 10:22

You got it. And this is one of the it's really frustrating as a provider where you want you know you can help that patient in front of you. You want to. And you know, their insurance should pay you. Right now, we can go get a contract with a commercial payer if they agree. Um, for certain services in the state, both commercial and Medicaid are mandated to pay, but commercial can electively cover more than Medicaid can right now. And if you have Medicare, uh we we can't help you unless you pay cash, which oftentimes, I mean, pharmacist delivered care can be very cost effective, but it doesn't mean there's no cost and it's not something that everyone can pay out of pocket for.

SPEAKER_01 11:00

So do you think that that message resonated that like there can be two two customers right there? And to like, did the did the legislators understand that? Do they understand that that's going on?

Medicaid Access

SPEAKER_00 11:13

I don't know if they understood that was going on because it and I think that is a a learning point that they do take away, and it's something we try to hammer home, is that like right now, as it stands, there are some national chains in in the state who are delivering test-to-treat services, but it's on a cash pay basis. So you know it's it's yeah, right now you can access this if you can pay, or if a commercial plan has come you have commercial coverage. And when you do really point that out, that's our message with the Medicaid um coverage bill that we're trying to get through is this is not new care. This is care that's already delivered. We just want to allow your patients to access it.

SPEAKER_01 11:55

Yeah. And when I ask if they understand, it's not it, it's it's a matter of it like being sort of like confounding that it could seemingly be so arbitrary about who can get access to what care in this this sort of setting. Um anything that you have for advice, like it seems like a great um indicator that you were asked to come back in this interim session and and share more and educate more. What do you think went well leading up to that in terms of getting sort of awareness so that there's the opportunity to come back and continue to try and um make progress even in an interim?

Relationship Building

SPEAKER_00 12:34

Yeah, um, that's a great question. And realistically, it's you need to build relationships and reach out to your legislators, especially um those who directly represent you. It doesn't always have to be necessarily pharmacy related. As pharmacists, we have an opportunity to reach out and be like, hey, you know, find out who your state assembly member is and find out who your state senator is, and reach out and introduce yourself and let them know that, hey, I'm in your district. I am a licensed pharmacist. I am you know very interested in obviously helping advance the scope of pharmacy, but I would like to, you know, let you know I'm open to any questions you may have, healthcare related. Um, and just introduce yourself and get get that, get your name out there and let them know that you're willing to work with them. We've often had legislators come back who we've gone to to educate or ask them what their thoughts are on bills we're trying to get forward, who then come ask us questions about other priority topics for them that are either healthcare related or adjacent. And just have letting them know that you're not just there just that you know for your own interest, but you're open to discussing other things with them, I think really helps uh get you an audience and build a relationship that can lead to meaningful change.

SPEAKER_01 13:51

Yeah, I love that. I think that's a takeaway that all of us can think about establishing those relationships and being available there as a resource to help in understanding, education, and uh and maybe even collaboration around a variety of topics, not necessarily the one that you're there talking about today. So I love that. I think it's a great reminder and a great takeaway. Well, Zach, this we can keep this one kind of short, it's informal. Really appreciate the update from you. Sounds like the pro next step would be we have to wait until the next full session. Is that right for something more formal to happen?

SPEAKER_00 14:25

Or

Interim Committees

SPEAKER_00 14:26

so we have some steps going on before next session. Um, we were invited back uh to a different standing committee. Uh the committee we just presented to was the interim joint standing health and human services committee. So it's more healthcare policy, but it focuses a little bit more on the finance side. Yeah. Um, we also were invited uh to present, I believe, if I'm recalling correctly, it's the Joint Ways and Means Committee. Um, but this one is a committee where our uh scope expansion bill hit last session. So it's kind of a every state legislature has different committees that kind of hear different topics, and it's not always the same committees where healthcare finance and healthcare policy wind up. Um, but we were invited back to give a similar presentation to an additional standing interim committee, which again is a positive indicator that there is interest, there's continued interest, and that these are likely bills that we will be able to introduce in the next session. Yeah,

Next Session Plans

SPEAKER_00 15:28

but nothing can be introduced this year. We are going to have to wait till next year for our active legislative year. And we also know that at least for one of the bills, we need new sponsors because our sponsor for the bill who introduced it was a pharmacist member of state legislature. He has retired, he's not running for re-election. And so, right now, these discussions are not just to educate individuals, but it's also to find individuals who will hopefully sponsor and introduce these bills.

SPEAKER_01 15:56

And that goes back to the relationships point, I think, right?

SPEAKER_00 15:58

Yep, exactly.

SPEAKER_01 16:00

Well, thanks for being out there and doing the good work, Zach. Uh, keep us updated as things we chat again after the next session um next time you're there and um hear what's going on. But thanks for joining me. Quick one. Um glad to have you on. Thanks for sharing your story.

SPEAKER_00 16:16

Absolutely. Thanks for having me.

SPEAKER_01 16:18

And uh look for us again on the next episode of ECAP Watch.