Bakersfield pharmacist Ryan Gates knows how to work a room. Wherever he goes, people seem to know him. He, in turn, knows them, not just names but details about their families -- whose mother is sick, who just had a baby.
"He's really charismatic. A real statesman," said Jeremiah Joson, a longtime friend who works with Gates at Kern Medical Center. "At industry events and conferences, he shakes the hand of everyone in the room.
"He always tells me it's important to network because even if you don't need anything now, you never know when you're going to need someone's support in the future."
For the last two years, Gates, 40, has been putting that skill to good use. In October, Gov. Jerry Brown signed a landmark bill into law that dramatically redefined the role of pharmacists in California.
Effective Jan. 1, they are legally recognized as health care providers, not just dispensers of medicine. The law grants new authority to furnish hormonal contraception, nicotine replacement products for smokers trying to quit and travel medications for people going overseas.
Pharmacists can also order and interpret tests related to a patient's medication regimen.
Some pharmacists had already been providing clinical care. Vaccinations have been available at drug stores for years, for instance, but now for the first time pharmacists can directly bill insurers as health care providers.
The California Board of Pharmacy on Wednesday held its first meeting on the details of implementing the new law, a process that's expected to take at least a year.
But that's expected to go smoothly. The real battle was won last year when Senate Bill 493, the Pharmacist Practice Act, passed both houses of the state legislature. It wasn't an easy fight, and Gates played a major role in nudging the bill to victory.
"Once we got to the capital, we really needed a pharmacist who could speak to what was happening in health care," said Dawn Benton, CEO of the California Society of Health-System Pharmacists, or CSHP. "Through his living in Bakersfield, he was able to speak eloquently and knowledgeably about the problem of not having enough providers to meet the needs of patients and the work he's done to try to meet that need.
"He really was a key witness for us."
Gates testified in Sacramento three times and was involved in drafting the bill and lobbying for it from its infancy.
THE BIRTH OF A BILL
In 2012, Gates was in Anaheim for a CSHP conference with fellow KMC pharmacist Matthew Dehner when the two got a bite to eat at an ESPN Zone and started talking shop.
President Obama had signed the Patient Protection and Affordable Care Act into law two years earlier in 2010, and both were concerned about an anticipated surge in demand for health care.
"The law expanded access to insurance but didn't do anything to add one single health care provider to provide care," Gates said. "Especially in areas like Kern County, we already didn't have enough physicians, and now it was going to be even worse."
The two started jotting down notes on a napkin. Those notes are what eventually became SB 493.
It was a long, meandering journey, though.
There are two big trade organizations for pharmacists in California. Along with the CSHP, there's the California Pharmacists Association.
Pharmacists in that organization had the same idea, so at one point there were two committees working on similar legislation.
Gates chaired the CSHP committee, and was also a member of the California Pharmacists Association committee then chaired by Sarah McBane, now the association's president-elect.
Gates and McBane both believed it was silly for the organizations to work separately on the same issue, so they combined the committees into a joint task force they co-chaired.
"At the first meeting, by about noon Sarah and I had lost all hope," Gates recalled, chuckling.
The task force was unwieldy with about 20 members, each with different agendas. Community pharmacists who owned independent drug stores didn't always agree with pharmacists at big retail chains, not to mention the pharmacists who worked for hospitals large and small.
Eventually they worked it all out, though, and Gates helped keep the peace.
"Initially he may come across as a little bit quiet, at least he did to me," McBane said. "But I've come to really appreciate his leadership skills.
"He's very good at hearing people out, but when the conversation kind of wanders out into the weeds, he's good at pulling them back to the topic at hand."
The task force found a sponsor in state Sen. Ed Hernandez, D-West Covina, an optometrist also concerned about demand for health care outstripping supply.
The next step was to overcome opposition from doctors, some of whom were wary of potentially competing with pharmacists for patients.
Others wondered whether pharmacists were qualified to do the work.
But pharmacists had a few allies in the medical profession, including the California Association of Physician Groups, because overwhelmed doctors in physician groups often were already delegating some routine tasks to nurse practitioners and physician assistants.
The industry worked collaboratively with doctors to address their concerns with various amendments. In time, the California Medical Association changed its stance from opposed to neutral.
Among the concessions was that pharmacists would be allowed to furnish certain drugs, but not prescribe them. The difference is they can give a patient medication they have on site, but they can't write a prescription to be filled elsewhere.
The pharmacists also agreed to more rigorous standards for a new category of pharmacists called advanced practice pharmacists.
A NEW KIND OF PHARMACIST
Although all pharmacists are now technically health care providers, the subset of advanced practice pharmacists will have broader powers to assess patients provided they meet two of three criteria, up from one in the original language of the bill.
The criteria are:
* Obtain certification in a relevant area of practice such as geriatric pharmacy, oncology pharmacy or some other specialty,
* Complete a postgraduate residency in which at least half the training is in direct patient care services, and/or
* at least one year of experience providing supervised clinical services.
The problem now is that there isn't nearly enough capacity in the state's pharmacy residency programs, but Gates thinks that will change.
Now that pharmacists can bill insurers for patient care, there's a new incentive for additional residency programs to be created, he said.
HOME GROWN CHAMPION
A senior clinical pharmacist who directs the residency program at KMC, Gates has been helping the hospital's diabetes patients manage their disease ever since he was hired in 2005.
He graduated from Highland High School in 1992 and attended Bakersfield College before transferring to Humboldt State University, where he majored in environmental biology and minored in botany. That came in handy during a stint fighting wildfires with a hotshot crew.
Gates taught high school science, physics and biology in Colorado for a few years and coached the school's wrestling team, but his older brother had decided to go to pharmacy school and talked him into going, too. Gates finished University of the Pacific's pharmacy school in 2004, then headed over to a residency program in San Diego.
As luck would have it, a childhood friend was down there, too, a pretty critical care nurse named Heather Fisher who is now his wife and the mother of their two sons and three daughters ages 18 months to 6 years old.
"She was my first kiss at 7 years old in first grade," he said. "It was a plot by the girls at Jennifer Massey's birthday party at Rollertown. She tackled me and I feigned resistance."
The residency program with the Veterans Administration in San Diego emphasized diabetes, which was of particular interest to Gates.
Kern County leads the state in deaths from diabetes and doesn't even have enough primary care doctors, much less endocrinologists.
Gates said he enjoys working with diabetes patients.
"All the things I loved about teaching are still here," Gates said. "Especially directing the residency program, I'm still teaching and mentoring. And so much of diabetes care is educating patients, helping them get control of their disease and get their lives back."
It didn't matter that Gates couldn't bill insurers for his services before the law was passed because KMC gets government funding to provide care for the poor.
But now, all pharmacists will potentially be able to play a greater role in helping patients in Kern and other underserved areas, and Gates is really proud of his role in that, even as he emphasizes that he was one of many people who made it happen.
"I had an opportunity to be in the right place at the right time with the right story to tell," he said.