Health & Medicine
The pharmacist will see you now
Can these medication experts bolster U.S. primary care?
Community pharmacists fill prescriptions, answer questions about drug and food interactions and run CVS and Walgreens outposts from Florida to Alaska. Could they also bolster primary care amid a general physician shortage? And if so, how can they help?
These are the deeper inquiries that VCU professor Dave Dixon, Pharm.D., and researchers from Canada and New Zealand invite in a study they released in November examining what might happen if U.S. pharmacists could treat patients who have high blood pressure.
Dixon, chair of the Department of Pharmacotherapy and Outcomes Sciences, is the lead author of the paper, which was published in JAMA Network Open. It finds that allowing pharmacists to treat hypertension could prevent 15 million heart attacks and nearly 8 million strokes over 30 years, and save $1.1 trillion in health care costs.
The study connects a handful of patterns: 1 in 2 U.S. adults (about 120 million people) has high blood pressure; the Association of American Medical Colleges projects a shortfall of 17,000- 48,000 primary care doctors by 2034; and about 95% of Americans live within 5 miles of a pharmacy, helmed by a medication expert with a doctoral degree.
“Only 1 in 4 U.S. adults with hypertension has it under control,” Dixon says. “And with chronic diseases like hypertension, a lot of times we need to use medications. To have someone able to focus on that — increase the dose, modify the drug regimen — requires a lot of touches. And that’s where I see pharmacists fitting in. Because right now there’s really two issues. One: If you try to establish with a new primary care provider, you’re probably not going to get an appointment tomorrow. And then, with whatever chronic disease you might be dealing with, it’s going to require regular follow-up. That places enormous strain on primary care clinicians.
“There’s an immense opportunity here to leverage pharmacists. And they are on nearly every [street] corner.”
But it’s not that simple.
America’s fee-for-service health care model pays providers for services they perform. It values procedures that fix problems more than preventive care. The upshot, according to a 2021 report from the National Academies of Sciences, Engineering, and Medicine: General doctors earn less than specialists. And providers are financially rewarded for volume and complexity, not quality or results.
And so, primary care, the bedrock of American medicine, is teetering. Its share of practicing physicians has been declining for decades. The National Association of Community Health Centers estimates that more than 100 million Americans have trouble accessing primary care. A 2023 paper in JAMA Internal Medicine found less than 9% of third-year internal medicine residents planned to enter general practice, opting for specialty careers that can be two or three times more lucrative.
“America has three specialists for every primary care doctor. The ratio in the rest of the Western developed world is three primary care doctors to every specialist,” says David Nash, M.D., professor of health policy at the Jefferson College of Population Health in Philadelphia. “We do not have a physician shortage; we have a physician maldistribution. Among the reasons: One, annual income for specialists versus primary care doctors. Two, the culture of clinical training. Medical students are smart. They see who the heroes are, and the heroes in their training environment are not primary care doctors. And three, being a primary care doctor — most especially pediatrician, family practice, primary OB-GYN — is a gut-bustingly difficult job made harder today because of suicide, drug abuse, alcoholism and depression [among patients], all worsened exponentially by COVID.”
America “is in a jam,” Nash says. It needs more general doctors. But that would require national policy changes and take years.
“There’s no short-term fix,” Nash says. “So the short-term fix that’s being applied is [using] doctors of nursing practice, physician assistants, letting folks practice to the top of their license. This is the Band-Aid.”
The pharmacist-as-provider idea offers one way to improve provider supply. But it doesn’t fix the underlying physician problem, Nash says. Some things simply require doctors. And though we need fast fixes, too, those proposals often run into two barriers. The first is how the United States regulates what health professionals can do.
“States regulate health professions; they make their rules,” says Jean Moore, Dr.P.H., director of the Center for Health Workforce Studies at SUNY Albany.
Moore has studied health workforce regulation for more than 20 years. She says America’s structure has major flaws.
States restrict a health professional’s scope of practice to varying degrees, which means what someone can do is determined by training and geography. This creates yawning gaps from state to state between licensing and competency, a problem exacerbated when slow-to-modify regulations collide with evolutions in training.
“What we really should be doing is let- ting people do what they’re trained and capable of doing in all states, and that just doesn’t happen,” Moore says. “This whole thing kind of flies below the radar, but once you start looking, you’re like, ‘Seriously, this is our system?’”
Pharmacists in the profession’s early 20th century “soda fountain era” mostly compounded medications, filled prescriptions and ran a store. Though their descendants are trained to meet with patients and discuss their medication and health history, they remain mostly unrecognized as providers. And while pharmacy’s professional organizations have pushed for years to change this, the American Medical Association opposes it. The AMA’s position, from its website: Quality care hinges on doctors leading health care teams. In 2023, it helped block more than 100 state bills that would have expanded scope of practice for nonphysicians. (The AMA did not respond to an interview request.)
This is the second roadblock.
“When you start talking about regulatory change, you typically get organized dentistry, organized medicine saying ‘No, no, not a good idea,’” Moore says. “But there’s tons of research that suggests team-based care is some of the most effective care you can provide. So then the question is: Where do you draw the line? Who can do what?And how do we find a way to do it safely?”
“What we really should be doing is letting people do what they’re trained and capable of doing in all states, and that just doesn’t happen.”
The key, she says, is to assess the merits of scope-of-practice changes and improve training.
“Primary care is critical,” Moore says. “[So] to what extent are we training pharmacists, dentists, to look at some of the things primary care providers need to look at? Somebody’s hypertensive, and you could use certain medications that could help regulate that. But what about other heart issues? What about cholesterol? ... How does the pharmacist connect to the primary care physician? The cardiologist? What if you’re dealing with somebody who has multiple comorbidities?
“We need evidence. Why should we make this change? What happens if we don’t? Research that examines outcomes is important because people need to understand that story: Yes, pharmacists can do this safely under this circumstance.”
Nash, the health policy expert, says “allowing appropriately trained persons to work to the top of their license” is good policy in the short term. (In the long term, he says, “we’re going to have to address the primary care doctor shortage.”)
So will pharmacists have a larger role in the future?
“I think the storyline there is the complexity of pharmacotherapy,” Nash says. “The pharmacist’s role in appropriate drug administration has increased in its criticality threefold, fourfold, because of the complexity of all these drugs. Forty years ago, it was cancer chemotherapy. Now we need help across the board. Basically, it’s impossible for any single doctor to have all the drugs in his or her head.”
One example of the pharmacist’s evolution from soda shop manager to medication expert and beyond is the prevalence today of “collaborative practice agreements,” contracts between a pharmacist and a physician that let pharmacists provide a set of services. Dave Dixon, who still practices, has an agreement with a VCU Health cardiologist that allows him to adjust medication levels for returning patients.
These agreements don’t increase physician supply, but they are legal nationwide. And in 2023, lawmakers in 32 states passed 55 bills that either recognized pharmacists as providers, expanded their scope of practice or authorized payment for services. Among them: A Virginia law now requires Medicaid to pay pharmacists for services covered under state protocol or collaborative agreements.
Laws like these are why, depending on where you live, you can be tested and treated by a pharmacist for strep throat, flu and urinary tract infections. Regardless of the regulatory lever, Dixon thinks pharmacists, increasingly, will be coming “out from behind the counter.”
“I think we’re going to need that, especially because we have an aging population,” he says. “It’s going to be critical that we have a workforce to meet the demand. That’s where, for a lot of these preventative or chronic-disease type services, yeah, you might see a pharmacist, you might see a nurse practitioner, you might see a physician’s assistant. It’s going to take a team.”
