Experts Discuss Need for Advocacy in Pharmacy, Health Care

This episode features Kathy Pham, PharmD, BCPPS, who discusses her experience at the American College of Clinical Pharmacy (ACCP) and why advocacy is important to health care and the pharmacy profession.

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Christina Madison, PharmD, BCACP, AAHIVP: Hello everyone and welcome to another episode of Public Health Matters, part of the Pharmacy Focus podcast series with Pharmacy Times. I'm your host, Dr. Christina Madison, also known as the Public Health Pharmacist. I'm very excited to have another incredible guest with me here today, Dr. Kathy Pham. I have known Dr. Pham for several years and have been so excited to firsthand witness this incredible, female, phenomenal leader rise through the ranks of our professional organizations, and just really excited to see the impact that she's been able to make from her origins as a pediatric pharmacist now to being on the front line of policymaking and advocacy. Without further ado, I'm going to go ahead and let Dr. Pham introduce herself a little bit more, and then we're going to dive into some questions.

Kathy Pham, PharmD, BCPPS: Thank you, Christina, you have been such an amazing person to really get pharmacists more in the public eye. I admire all of the advocacy work you've done, and particularly in the public health space. That was a very kind introduction, but really, I admire you just as much if not more. A little bit about me: I am the senior director of Policy and Professional Affairs at ACCP. Ultimately, the work that I do is, I like to say, that I am lucky enough to be the person at the ACCP that tries to get everyone to want to work with us. It's a very collaborative space.

With my background, which I'm sure we'll talk about in a little bit, it's just really built up to being able to talk within and outside of pharmacy about how we can advance clinical pharmacy and clinical pharmacists, and it's just a really natural fit. I am very blessed to be able to really speak in my natural voice every day. I think with advocacy, it's always about how passionate you are about what you're speaking for. I know that you genuinely advocate for all of the issues and the policy advancements and everything to move forward on pharmacists and public health. Equally, it's an honor to be able to represent other clinical pharmacists like myself. In my 14 years of clinical practice, I am now representing those that are my peers, just like yourself. I'm really, really honored to be here and honored to talk about the types of advocacy that pharmacists can participate in.

Christina Madison, PharmD, BCACP, AAHIVP: That's incredible. With that being said, I'm curious, we were lucky enough to see one another because of my work within ACCP, and I've been super involved. And it's been amazing to see both of us go from members to being more part of the organization, and then you actually working for the organization. Then recently I was in DC, and I was able to meet up with you, which was incredible, and so again, I just want to know a little bit more about how that transition worked. Because, obviously, when we think about pharmacists in general, we often think about us working in some sort of a clinical space or working directly with patients. I know that that transition sometimes can be a little bit challenging, especially if you're somebody who's really dedicated to patient care. I'm just curious how did that transition work for you? And then, what did you do to prepare to kind of get more into this space, especially as you very eloquently mentioned, that you feel like you're able to speak in your natural voice, and to be your authentic self on a daily basis, which is incredible. I want to know sort of how that transition worked for you.

Kathy Pham, PharmD, BCPPS: Yeah, thank you. Well, I'm first and foremost a pediatric clinical pharmacist. And even though I'm not in daily practice, so much of that decade and a half in practice still influences how and the way that I advocate for not just the profession, but health care reform in general. I think that a lot of times pharmacists, maybe, are very humble and don't always see the applicability of their skills beyond their pharmacy practice, their day-to-day practice. And I don't think I appreciated that for a while as well, but, you know, pharmacists in general, when clinical pharmacists and then pediatric clinical pharmacists, each one of those takes on more and more advocacy, the more specific you get into your practice setting and your patient population. So, I am sure that everyone who's practiced in pediatrics, yourself included, knows [that] to speak up on behalf of our patients is one thing. To speak up on behalf of such a vulnerable patient population is another, and then to be advocating for a group who has very unique needs that are not inherently understood by everyone is another challenge.

And so, I would say that what's really helped in the transition was everything that I had really developed in my career, and particularly my communication skills to be able to speak to a wide range of audiences. The advocacy work in professional organizations kind of put me in a space that wasn't so much about what is the work that I do at my own institution, but how can this be a catalyst for change? Or betterment of staff, you know, beyond each hospital doing their own thing? How can we create resources or changes that can standardize safety initiatives, standardize a more effective way of doing things? And I think that advocacy just really starts with going beyond what is going to affect your unit, your patient, your immediate day to day responsibility, and looking at it in the bigger picture of like, well, how can I help others prevent this medication error, do this better and smarter and streamlined. And I don't think a lot of people understand that they're advocating in their practice all the time.

So, my transition was me just recognizing that those same skills that I was just kind of taking for granted as what I do every day, being able to apply it in a broader application to a broader audience, external stakeholders, is really similar to kind of going to your pharmacy and therapeutics committee or your C-suite and explain a need for something that they don't inherently want to spend money on. The evidence behind that, the persuasive communication that goes behind that, understanding what's in it for the stakeholder you're talking to—those are all things that I had been doing more institutionally. And I really needed just to understand how that was going to be applied in this new setting. The biggest transition was leaving clinical practice, and my first departure from clinical practice was to be a senior program officer for the Pew Charitable Trust. And I definitely did not have the training. There's a residency out there to be a pharmacist and a think tank.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, that's crazy. That's so cool, though. Just, like, an exponential learning curve and just hit the ground running.

Kathy Pham, PharmD, BCPPS: Yeah, yeah. I think that a lot of pharmacists don't give themselves enough credit for being able to pivot into those unique spaces. I didn't. The biggest challenge in the transition was my own confidence, and how many times have any of us experienced that in a career transition?

Christina Madison, PharmD, BCACP, AAHIVP: It’s called imposter syndrome.

Kathy Pham, PharmD, BCPPS: You could be a student starting your residency, you could be a resident starting your first position, you could be 20 years in and taking on a new role, and you're still going feel like, ‘Really? Me?’

Christina Madison, PharmD, BCACP, AAHIVP: Like me, who’s like, almost 20 years deep, and I'm, like, qualified, showing up to the White House being like...I mean, I remember us having dinner and we'd be like, “What are we doing?”

Kathy Pham, PharmD, BCPPS: I know. My favorite thing was like, oh, gosh, I’ve got to put my big girl pants on, you know? I feel good, but the girl panties on, right? And I don't know that any of us are ever ready. But I think there are certain professions out there that do a better job of as I say, they'll fake it ‘till they make it. And for us, we have such a strong integrity in our work and our expertise, that we will underestimate our expertise and then think that we cannot authentically represent that perspective or do that role. And so, my biggest revelation in all of these transitions is I'm much more prepared for this than I realized. Everyone, every person in any profession is going to have a learning curve when they first transition to something new. If you don't go in—even professional athletes are rookies for a reason their first year, right? Your playbook, you are still figuring things out. But it's not about knowing how that organization or how that policy making or how any of these things work in a single day. You don't come hitting the ground running, you take the skills that you've acquired up to that point that makes you qualified to take on those roles, and you start to build a better understanding of the context of the environment, the politics that are involved. All those things take time. And I think that for all of us who are transitioning, especially in policy, that can be a little bit intimidating. We are way more experts than some of the other people at the policymaking table. And you just need to own that.

Christina Madison, PharmD, BCACP, AAHIVP: To quote [Ruth Bader Ginsburg], I want to be in the room where it's happening, right? Like, you need to remember that you're more than qualified to be in the room where decisions are being made, right? You don't want to just be invited, you want to have a seat at the table, and to be able to contribute in a way that can make meaningful and lasting change. And I feel like, you know, in general, we as a profession are really terrible at being open about our accomplishments and what we have to offer. I always say we're the most underutilized component of the health care system and that we often don't know how to promote ourselves. I always say like, the profession needs a PR makeover. You know, I'm very braggadocious and I will brag about other people all day. But then when it comes to myself, I'm really bad about putting out there, like what I'm doing or even how I feel like I can make more impact than just myself. And I think, you know, that's part of why it's so important that we have professional organizations, supporting and developing and creating roles, like the role that you have, for purposes of advocacy. Because unless we have people that have our professional background in Congress, advocating for us [and] being our champion, we're not going to get things through. And it's not like we're lobbying, right? Like, there's a very different set standpoint between advocacy and lobbying. And I feel like people don't understand the difference, because there is this concept around like dark money and like people being paid to, like, go in and advocate for one side or another. That's very different from what we're doing at a professional pharmacy level. And I don't know if you want to maybe talk about a couple of the initiatives that you guys are working on, specifically in the realm of public health and advocating for some of the provisions that were put into place during the pandemic, for the emergency standpoint. But now that the emergency is probably going to be going away soon. What are some of the things that ACCP is advocating for and having you work on?

Kathy Pham, PharmD, BCPPS: Yeah, I think that it's important when we talk about public health, generally, most of us are inferring that the majority of the findings there is an infectious disease, right?

Christina Madison, PharmD, BCACP, AAHIVP: We're talking about preventing some sort of communicable illness.

Kathy Pham, PharmD, BCPPS: Yes, right. But public health is the health of the population and our communities and that really reaches beyond infectious disease. We're talking about blood pressure, we're talking about diabetes, we're talking about other heart diseases, autoimmune disorders. There's so much, both acute and chronic conditions that need to be treated well and get patients healthier in order to actually improve public health. So, although the public health emergency will come to an end—although, you know, you never know what's around the corner, I hate to be that person—but I think it's important for us. You know, ACCP throughout the pandemic has obviously spent quite a bit of attention making sure that vaccine hesitancy can be addressed by the expertise of our members, who are really well positioned to have meaningful patient and consumer engagement to talk about some of their concerns about vaccines, whether it's the COVID vaccine or otherwise. Again, you and I are both pediatric pharmacists, by practice experiences as well. And so, we've had to talk through some of those vaccine hesitancy issues well before COVID.

But I think that beyond the infectious disease side, you know, ACCP has been focusing on how to maintain good access, equitable access to care that will improve outcomes. And such a big part of that is advancing comprehensive clinical pharmacy services that patients can access in primary care and ambulatory care. And even in acute care, you were seeing comprehensive clinical pharmacy services provided a ton in new emergency departments, in critical care throughout the pandemic, just like you were seeing huge health care demand in primary care where a lot of our physician peers really needed to fully leverage the expertise of the clinical pharmacists on their team to continue to take care of their patients. People were coming in sick, people were starting to ignore their chronic health conditions, so in general, there was a continued increase in health care demand at a time when the workforce is really short, pharmacists and otherwise. So, I think that for ACCP, our initiatives are focused on practice advancement, practice transformation that fully leverages the expertise of clinical pharmacists to create that team efficiency.

So, some examples of that is our interprofessional work on the Primary Care Collaborative, which is a diverse group of state stakeholders trying to improve the quality of primary care and maintain the relationships that are essential to primary care. Unfortunately, like everything else, it's under invested. And when it's under invested, access suffers. And so primary care is one of those examples. We are also collaborating with the Alliance for Addiction Reform, which is trying to merge those. Addiction recovery is a chronic condition, just like our other chronic conditions that we manage for our patients, but trying to explore addiction recovery in the medical home model and an alternative payment model that will actually create a way for care teams to be able to give the care to those patients throughout the continuum of care, whether it's episodic and otherwise, and also in a comprehensive, coordinated way. So, both of those are examples. And then obviously getting the medications right is another ACCP initiative that has another great set of diverse stakeholders as well. We have done so much great work and there's so many advocacy resources, if you visit the webpage for Get the Medications Right. But that's another one where some of the other ones are bigger focuses, right? Primary care and addiction. But the Get the Medications Right Institute is specifically looking at medication optimization and how comprehensive medication management can achieve medication optimization.

But in all 3 of those examples, it's really about being at the table with policy influencers, whether they're lawmakers, government representatives, payers, employer groups, patient advocacy groups. They're all important voices to be at this table because pharmacists will not advance team-based care if you don't engage all other stakeholders on the team. And so, we tend to really do interprofessional collaboration with these broader coalitions and trying to make sure that in any of those areas where medication management is relevant, that we are providing that perspective. Because to your point, what you said earlier, when we're not at the table, other people are going to make that policy in our absence and we're going to end up experiencing the downstream effects of those policies when it becomes implemented. So, we need to be at the table. And we not only is ACCP invested in being at the table, but we also need to pursue ways that individual pharmacists feel comfortable trying to make their way at the table, whether it's professional development in areas of policy, advocacy, and public health, or, you know, just demonstrating passion and trying to connect people to feel comfortable leveraging both their clinical practice and their passion for advocacy to affect change.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, I couldn't agree with you more. I mean, I feel like when we look at the diaspora of things that we can advocate for, you know, I always say especially within public health, it's the health of the many versus the health of the one. And when you impact one life, you don't just impact that person. You therefore impact the ability for that person to be a productive member of society, to be able to be the breadwinner for their family, which then in turn provides more health and wellness for the entire family, which then includes them being productive members of society. So, it's a ripple effect, right? You keep continuing to engage. And then more and more health and wellness benefits come from doing more on the preventative care side, versus waiting for somebody to have an acute issue or to end up with a chronic medical condition. And I think that's the thought process that a lot of time. We don't realize, especially when I talk to pharmacists that are like, “Oh, how did you decide to get into public health?” I'm like, literally every pharmacist is a public health pharmacist, like anybody who's doing vaccinations, anybody who's counseling on self-care, OTC—every pharmacist, in my mind, is a public health pharmacist. Right? And I think the biggest thing for me from an advocacy perspective is understanding the necessity to look at all aspects of what we do through an equitable lens. And I think that is something that, unfortunately, we saw during the pandemic, how bad a job that we're doing with making sure that care is being accessed in an equitable way. And so, I think, you know, before we can even get to the point where we're able to advocate, we need to make sure that we're looking at things from an equitable lens. And that includes making sure that everyone in your population has access to whatever services you provide equitably, meaning everybody has the same access. And all things are fair and are just.

Kathy Pham, PharmD, BCPPS: I completely agree. And I honestly think that the type of comprehensive clinical pharmacy services that ACCP members provide are a great display of equitable access to a better care model. You're talking about clinical pharmacists being embedded in concierge medicine practices, okay. But you're also talking about clinical pharmacists, in areas where the workforce shortage is sometimes the most dire. We're talking about the VA, pharmacists in the Indian Health Service and other sectors of public health, in the federally qualified health centers, the FQHCs. All of these areas are in those settings where they have to make the most of the workforce they have. It's all hands on deck, it takes a village. There is no, “You're encroaching on my scope of practice.” It’s “We need to all be leveraged on this team to be able to see the patients when they need us.” And I think that that's where ACCP members really can showcase that service. When we actually take away the limitations and barriers to being able to expand clinical pharmacists in different areas, it will drive health equity, because we are improving the quality for all those that we can reach. It's not just for specific private sector practices. That comprehensive medication management is provided in all sorts of settings, and sometimes in the most underserved populations. So, I love that I'm able to try to pass that message along to lawmakers, that this could be equitable, but there are barriers in the policy that are getting in the way of being able to expand this.

Christina Madison, PharmD, BCACP, AAHIVP: The other thing, too, is understanding that, especially when we think about patient care and advocacy, we're understanding that there are people that may be hesitant to engage in the traditional health care system because of issues around historical trauma, systemic racism, and not feeling like they have a place because they're being othered, or they feel like they may be judged. Especially in the substance use space, we see a lot of people not engaging in the health care system because they feel like if they're using, if they're actively using and they have children, they feel like CPS is going to get called on them, or they feel like they may lose their job because you have a duty to disclose, but they don't understand that the laws protect them from getting that information out to people that may not understand that they're seeking help. Right? And so, again, I think policy and advocacy is the way to make meaningful, sustainable, impactful change, and so you can do all the things you want in your little silo, but it's only going to impact that little silo unless you directly think about legislative change, policy change. Like at your county level, your state level, and then at the federal level. And so, I don't know if you want to maybe talk a little bit about that and sort of how that works. And I know we don't have that much time, but maybe if you can just kind of like briefly explain sort of like the levels of government and sort of like, how things come to be. Obviously, you need a champion but yeah, I'm going to let you talk about it.

Kathy Pham, PharmD, BCPPS: Yeah, I mean, I think with legislative change, we have seen in many years now that legislative change is slow, at least at the federal level, right? You can just watch the news and know that Congress is having a hard time getting through, and we're in an even more divided Congress right now, everything is pretty even. And so hopefully, that means there'll be some compromises to move some things through. But, you know, that has yet to be seen. And so, I think what we've seen is even if the legislative change happens at the federal level, let's say tomorrow something happens where CMS is able to establish a benefit for clinical pharmacists to provide care, essentially saying CMS will pay pharmacists to deliver services and recognize them as a provider within Medicare. But there are so many working pieces that happen after that legislative change. And the last legislative change is going to be speaking at a much higher, broader level. It is not going to go into the weeds of how it's going to get paid for, who is going to be the person that will be providing the service, how will we know that they're qualified to provide these services. All of that is actually the policy implementation that works its way down from that law change, down through the CMS and other payers, figuring out how to implement that policy change. And then assuming also, if this light switch turns on, that there are all these care teams with other health professionals that know immediately what they're supposed to do with it. That is another major barrier. And so regardless of what happens legislatively, it's all this other stuff that gets worked on.

While we're waiting and seeing if Congress can make a change, it is working with payers already to see if they would like to explore payment models, just like the alternative payment model for addiction that we talked about with the Alliance, where it's working with other health professional organizations in our network. With the Primary Care Collaborative, getting them to understand how integrated clinical pharmacy services works, what comprehensive medication management means, who are the patients that you see that can benefit most from that, because not everyone needs certain levels of clinical pharmacy services, but the ones that do, when they have complex chronic conditions, you want a clinical pharmacist essentially acting as the care coordinator of medications for that person.

So, I think unfortunately that mean that we're spread out really thin, because we have to work on all those things at the same time. And that's really where interprofessional advocacy helps. The other thing, too, is if things are at a standstill at the federal level, what we've seen more is progress at the state level. States passing provider status legislation or more states increasing the medical or pharmacy benefits to be able to provide more and more clinical services to help optimize medications. So, in the meantime, as much as we want to find sponsors for the bills and move bills forward through Congress, this has been something that has taken decades, but we have still made progress by convincing other people on the team that they need us. And not just the individual, although that's really important. Pharmacists can be advocates every day by just being the best care team member they can for their patients and convincing everyone else why clinical pharmacists are a godsend, right? Like, that is as grassroots as it gets. But interprofessionally, the other physician organizations, nurse practitioner and physician assistant organizations, the patient advocacy organizations, they all really need to understand the value of what an efficient team looks like. So, we have to still also work at the national level with the health professions so that they can also better understand that, again, if that light switch turned on tomorrow and you could finally get payment for clinical services, what does that mean? And who do I want on my team? And ACCPs work is really convincing those people that who you want on your team are clinical pharmacists.

Christina Madison, PharmD, BCACP, AAHIVP: Absolutely. Wow, this has been such a great conversation. I so appreciate the work that you're doing and I really wanted to highlight that and to provide a little bit just a snapshot of what you're doing sort of behind the scenes. You've been in this role for 4 years? Is it almost 5 years?

Kathy Pham, PharmD, BCPPS: Yeah, yeah.

Christina Madison, PharmD, BCACP, AAHIVP: So, I mean, because I remember. It's so interesting, because like I said, I've had like, a VIP seat to see your amazing transformation over the past few years. I remember us going to the reception at annual, and you talking about how you're like, “I really think I want this job, but I don't know if I'm qualified.” And I'm like, “Girl, you are, like, the most [qualified].” Again, I think, what we can leave the audience with is empowering people to understand that you are way more than you probably give yourself credit for. Be braggadocious. Talk about how wonderful you are, or at least find a friend, or talk about how wonderful you are, right? And I think that it can make all the difference. And then really, you know, advocacy doesn't have to be this grandiose thing. It can start small. And again, making those little impacts, you have no idea the ripple effect that that could make. And so, if you're wanting to start off doing things in a more equitable manner, increasing access to services, talking about the benefits of having pharmacists as part of an interprofessional team, you know, you can start small and that's fine. But if you do want to do things on a bigger, grander scale, I would say get in touch with Dr. Pham, do more advocacy work with your state or regional professional pharmacy organization. Obviously, we're talking about ACCP right now, but I would say this is really something that can be done for all of the different pharmacy organizations. It's not only specific to ACCP. All of our national pharmacy organizations have very similar advocacy departments. Obviously, they have different initiatives that they're working on internally, but that's the way that you can get involved, be involved with your state and your local pharmacy organization and start from there. And then, you know, get the word out. Obviously, not everyone likes to be on camera necessarily, or do podcasts. But you can do things like writing op-eds, you can contribute to your local paper, you can, you know, contribute to pharmacy journals like Pharmacy Times, right? That's who's sponsoring our podcast today. You know, there's so many different ways that you can make an impact that don't have to be, you know, going to the Hill, which is what Dr. Pham does, which is freaking awesome, by the way.

Kathy Pham, PharmD, BCPPS: But also, let the Hill come to you. I would also just add, don't be intimidated to meet with lawmakers and invite them to your practice setting. Show them what you do in a team, because their only understanding of pharmacy might be their minimal interactions in a pharmacy if they're also on very minimal medications. They might not know what chronic, complex, acute, or chronic looks like. So, I think people are intimidated even going to their state legislator, because like what do I talk about? Well, first of all, you can definitely reach out to ACCP or your professional home and there will always be resources for, you know, how you might want to lobby or put together a Legislative Day. There's talking points that you can get from your professional organizations. But really going back to how we started, which is being your authentic self and speaking in your natural voice, which apparently has worked for me professionally. I really encourage everyone to do the same. And the braggadocious part is not just about you but show off what you do in that practice and that health system, in that institution, because for lawmakers and policy influencers to see it firsthand is different than your 1-page leave behind and telling the patient's story. Maybe not why I need to be a part of the team, but the patient story of how my patients benefit from me being a part of that team, that could be really impactful. So don't be intimidated to make those, to reach out and have them come to you and see what you do.

Christina Madison, PharmD, BCACP, AAHIVP: I couldn't agree more. Those impact statements, those patient testimonials are extremely impactful. They're very persuasive. I participated in a Senate hearing last year, and it was around the Inflation Reduction Act, and we had a patient come in talking about how important it was that they had access to a Medicare call center that helped them to choose the right plan so that they could get the medication paid for that they needed, and then also talked about the impact of the lowering and capping of insulin prices. And it was just, I mean, it was so compelling, you know, listening to this woman talk about her story, talking about her struggle being able to afford her medication, and what a Godsend it was to not have to worry about how she was going to pay for her meds and not have to ration her medication. I mean, like that alone, I think it changed. You could tell, like, the whole demeanor in the room changed after she made her statement. And so, it's things like that. You know, it's just one person, but in the right placement, it could make all the difference and could really change the tide from a policy and an advocacy standpoint.

Well, unfortunately, we have to end our time together. It makes me so sad because I love chatting with you, Kathy. And I'm so incredibly grateful for the work that you do. And I'm just really in awe of the impact that you've been able to make. And I'm sure you will continue to do even more in the coming months and years. So, if people want to find you, or if they want to find out more information about the work that you're doing, how can people get ahold of you?

Kathy Pham, PharmD, BCPPS: Absolutely. You can visit an ACCP.com and there's a tab right on our webpage for our government and professional affairs work, so you can navigate that. And my contact information should also be on there. But I have a quick email—kpham@accp.com. But definitely peruse the website. ACCP is also trying to be better about putting out communications that help really distill our advocacy approaches and strategies, so we're always willing to also talk to folks if you want to schedule a meeting. But start there, get some information, and absolutely reach out by email and we can keep the conversations going.

Christina Madison, PharmD, BCACP, AAHIVP: Fantastic. Well, thank you so much again for your time today. And just to let everyone know again, my name is Dr. Christina Madison. I am your host for Public Health Matters, which is part of the Pharmacy Focus podcast series for Pharmacy Times. I am reachable on social media @thePublicHealthPharmacist. Continue to follow us for new guests and podcasts. There are so many different episodes that you can access. But you can click on our link to see more episodes. We'll be doing both audio and video recordings once a month, so look out for us and, as I always mention at the end of my episodes, remember public health matters.