Key takeaways from the U.S.-Canada Pharmacy Forum

In late March, retail pharmacy thought leaders from the United States and Canada gathered in Toronto to learn from one another about important issues facing the industry in both countries.

Co-hosted with the Canadian Pharmacists Association, the two-day event saw participation from key retailers, including Walmart, Walmart Canada, Rite Aid, Publix, Walgreens, CARE Pharmacies, Thrifty White as well as rep from other major organizations, including the National Association of Chain Drug Stores.

In case you missed it, check out the recaps of the sessions:

The Role of Pharmacy Within the Canadian Health Care System 

Joelle Walker of the Canadian Pharmacists Association opened the forum with a detailed overview of Canada’s universal healthcare system, emphasizing its complexity due to privately owned pharmacies and province-specific regulations. Canada boasts 47,000 pharmacists (118 per 100,000 people) with a rapidly growing generic drug market (75%). Despite this, labor shortages and burnout remain serious concerns, especially in rural areas. A study in New Brunswick suggests the number of pharmacists must double in smaller provinces within the next decade.

Walker stressed the importance of allowing pharmacists to practice to the full extent of their training. She introduced a campaign to showcase pharmacists’ capacity to deliver more healthcare services if regulatory limits are lifted. Pharmacy benefit managers were flagged as a major risk to the industry, with Express Scripts’ new service fee drawing particular concern. The CPHA has submitted a complaint to the Competition Bureau and is exploring regulation at both provincial and federal levels.

Ultimately, Walker’s message centered on learning from both Canadian and U.S. systems to ensure pharmacists are empowered, accessible and properly utilized in the broader healthcare landscape, especially as millions of Canadians still lack access to a primary care provider.

Understanding the U.S. Pharmacy Landscape 

Alex Adams, director of the Idaho Department of Health and Welfare, discussed the evolving landscape of pharmacy practice in the United States, with a focus on Idaho as a national model for regulatory innovation. Adams led significant reform as head of the Idaho Board of Pharmacy, shifting laws from rigid regulations to a flexible, standard-of-care-based model.

Idaho eliminated detailed regulations, replacing them with just 14 pages of statute, allowing pharmacists to operate within the bounds of their education, training and a generally accepted standard of care. This approach enabled rapid innovation, supported advanced services like independent prescribing, therapeutic substitution, lab test interpretation and vaccine administration. Idaho now even permits technicians to prescribe certain products.

Adams distinguished between legal “scope of practice” and actual “clinical ability,” advocating for recognition of pharmacists’ individual competencies. Adams predicted more U.S. states will adopt this standard-of-care model and stressed the importance of separating scope from payment to encourage service uptake. Though corporate chains often underutilize expanded scope, states like Idaho serve as a pilot for innovation that could spread nationwide, creating a flywheel effect for broader change, he concluded.

Actionable Advocacy: Advancing Scope of Practice in Canada

A panel featuring Alex Adams, director of the Idaho Department of Health and Welfare; Justin Bates, CEO of Ontario Pharmacists Association; Allison Bodnar, CEO of Pharmacy Association of Nova Scotia; and Margaret Wing, CEO of Alberta Pharmacists Associations, explored how Canadian provinces have advanced the scope of pharmacy practice and the impact of these changes on healthcare access, system sustainability and patient outcomes. While the journey has varied across provinces like Nova Scotia, Alberta and Ontario, a common theme was the shift from viewing pharmacists as dispensers to fully integrated primary care providers.

In Nova Scotia, pharmacists have led the way in operating clinics that separate clinical services from dispensing workflows, leading to improved efficiency, high patient satisfaction and meaningful reductions in ER visits. The pandemic was a pivotal moment, prompting governments to embrace pharmacist-led care and enabling widespread vaccine delivery. These clinics now operate at near capacity and are tightly integrated into the province’s health systems.

Alberta, a pioneer in full scope authority, experienced early stagnation due to a lack of funding and business models but later secured comprehensive public reimbursement for clinical services. Now, pharmacists provide more than 4 million prescriptions annually, with injections, renewals and minor ailments making up the bulk of services. Alberta serves as a model for sustainable pharmacist-led care.

Ontario lags behind but is gaining momentum. Although progress has been incremental, public support, pandemic-era gains and mounting political pressure have advanced services like immunizations and minor ailment prescribing. However, tension with physician organizations and fragmented regulatory frameworks remain challenges.

Speakers emphasized the need for harmonized, standard-of-care models across jurisdictions to ensure pharmacists can fully leverage their training and fill gaps in the healthcare system.

Pharmacist Led Clinics

Dave Puri, senior vice president of pharmacy at Shoppers Drug Mart, presented on the expansion of pharmacy-led clinics in response to Canada’s healthcare access crisis. With 6.5 million Canadians lacking a family doctor and increasing strain on emergency departments, Shoppers Drug Mart saw an opportunity for pharmacists to fill a critical care gap. In 2022, they launched their first pharmacy care clinic in a grocery store in Lethbridge, Alberta. The success of that pilot—with lines of patients on day one and national attention—validated the model.

Building on this, they introduced clinics across provinces, like Nova Scotia, and created a new “Care Concierge” role to streamline patient intake and support pharmacists in delivering care. In 2023, Shoppers Drug Mart began integrating these clinics into all new store builds, reimagining pharmacy workflows with enhanced technology and patient-focused layouts.

To scale, they pursued both new store builds and selective renovations, prioritizing areas with favorable reimbursement policies. Key challenges included staffing, training, standardization, and proving clinical quality. Despite these hurdles, they plan to reach 260 clinics nationwide by the end of the year, already having served 1.5 million patients in 2023 alone—positioning pharmacy as a central pillar in accessible Canadian healthcare.

Pharmacy Based Primary Care: A Business & Care Success Story

Canada’s largest pharmacy groups shared their experience and early findings implementing new services and creating new models of care. Moderated by Kevin Host, senior vice president, Walmart U.S., the panel featured Brent Evans, McKesson Canada, Jim Johnson, Sobeys and Jeff Bootler, Rexall.

The panelists agreed on some key points: 

1. Pharmacist-Led Care Is Valued by Patients
-Patients appreciate faster, easier access for minor ailments.
-Examples show people driving long distances to visit pharmacies rather than wait in hospitals.
-Patients report high satisfaction and express willingness to return.

2. Lack of Awareness Is a Barrier
-Many patients are still unaware of pharmacists’ full capabilities.
-More education and awareness are needed to maximize impact.

3. Workflow Integration Is Critical

-Independent pharmacies need flexible strategies to integrate new services.
-Coaching, booking tools, dedicated time slots, and staff training are key enablers.
-For larger chains, central support and technology can help reduce administrative burden.
 

The panelist concluded that pharmacist-led care enhances access and quality in healthcare, especially in underserved areas. The path forward, they said, involves better public awareness, supportive workflows and continued innovation in pharmacy practice.

Pharmacies will have to overcome a few challenges: pharmacists juggling multiple systems (11 to 12 apps), making it cumbersome; some pharmacy software is too transactional for clinical work and frustration with limited scope in some provinces despite being trained to do more.

Building the Pharmacy Workforce

This panel looked at how the pharmacy workforce must adapt to meet increasing demands and new opportunities as pharmacists take on expanded roles in patient care. The session looked at how Canada is preparing pharmacists for expanded scope roles; addressing shortages, burnout and recruitment gaps in pharmacy; and leveraging pharmacy technicians and automation to maximize capacity. 

Panelists includes Purya Sarmadi, MedMe Health; Lawrence Varga, Costco; 

Kyle Wilby, Dalhousie University; and Bev Zwicker, Nova Scotia College of Pharmacy.

Wilby said pharmacy schools must focus on foundational clinical reasoning, not just specific ailments; teach students how to think, not just what to do; offer experiential training to prepare students for real-world decision-making and make sure students learn to be comfortable making clinical decisions.

Varga stressed that pharmacies will need to optimize their workforce, such as shifting non-clinical work to pharmacy technicians, while Zwicker said the universities must look at a new framework that balances foundational education with targeted “how-to-apply-it” training.

In conclusion, the conversation highlighted the integration of education, regulation and innovation in meeting healthcare demands. It emphasized that collaboration, trust and flexibility across the system are essential for sustainable change.

Strategies to Address PBM Challenges

In this session, Christie Boutte, senior vice president, reimbursement, innovation and advocacy at the National Association of Chain Drug Stores, explored effective strategies and real-world insights from the United States on addressing challenges posed by pharmacy benefit managers . 

She highlighted impactful state-level reforms and innovative regulatory frameworks, offering actionable approaches that can be adapted to the Canadian context. Featuring insights from U.S. leaders in PBM reform, the session  tackled critical issues such as patient steering and callbacks, sharing hard-earned lessons to inform and inspire Canadian advocacy efforts.

Boutte said PBMs were originally created to simplify pharmacy transactions, drive cost savings and encourage generic use, but they evolved into powerful middlemen, manipulating drug prices and networks and profiting massively.

That evolution has hastened more pharmacy closures, low, delayed, or unpredictable reimbursements; excessive fees and spread pricing; tiered/differential reimbursement favoring PBM-owned pharmacies; patient steering to PBM-owned or mail-order pharmacies and restricted pharmacy networks.

Boutte said it has affected patients, too. Patients are often forced to use pharmacies not of their choice and forced to pay more out-of-pocket costs due to PBM rebate manipulation and formulary exclusions. It also has created a major health equity issue, especially in rural and underserved areas.

Her proposed solutions included transparency in contracts, reimbursements and fees; fair reimbursement models with defined minimums; any willing provider participation in networks; prohibited patient steering; accountability government oversight; and passing manufacturer rebates directly to patients.

U.S. Advocacy for PBM Reform

This panel looked at how advocacy efforts are driving meaningful PBM reform across the United States. It looked at the strategies and tactics that offer actionable approaches that can be adapted to the Canadian market.

The panel, which included Randy McDonough, incoming president of American Pharmacists Association, Summer Williams-Kerley, Rite Aid, and Christie Boutte, NACDS, kicked things off by explaining patient steering–when PBMs direct patients to specific pharmacies by altering coverage or copay structures–and the negative effects. It reduces choice for customers and damages long-term relationships with pharmacies, Williams-Kerley explained.

PBMs, Williams-Kerley said, are partly responsible for pharmacy closures in the United States, mainly due to unworkable reimbursement rates, while McDonough noted that 172 closures in Iowa alone in four years contributed to rising "pharmacy deserts."

There is some good news. Different trade groups–APhA, NACDS, NCPA–are working together more than ever before, advocating with a united front at state and federal levels; PBM reform still has bipartisan support but is delayed by other priorities, but progress is faster on the state level.

The panel offered advice for Canada as the country is considering using PBMs: Don’t let PBMs in without strict boundaries; start with clear rules on what’s allowed; and don’t let PBMs manage non-dispensing services to prevent cost-cutting at patient expense.