Primary Care Pharmacists: Provision of Clinical-Decision Services in Healthcare
To the Editor. Today, there remains a critical deficiency of physicians in the United States.1,2 Reasons for the shortage are multi-factorial and appear protracted over the foreseeable future, requiring other professions to provide primary healthcare services.3 Maintenance of the physician shortage has been attributed to an oversupply of medical specialists, Medicare caps on graduate medical training programs, and an unsustainable physician ratio of debt-to-income levels.3,4 Decades will be necessary to train sufficient number of primary care physicians.5 There are also insufficient nurse practitioners and physician assistants.6 Because these barriers are not changing quickly, the provision of primary healthcare is one of the most important issues of our time. 
 
Implementation of the Affordable Care Act identifies millions of newly insured patients needing primary care. Eighty million baby boomers are living with at least 1 chronic medical condition, accounting for more than 75% of healthcare costs.6 Acute care services provide healthcare for many patients, making the United States the world’s most expensive system. A new paradigm is needed to improve care.7 
 
Future healthcare models will offer an integrated primary care experience that is quickly adaptable to patient needs, localized around population-identified disease pockets, and operates under a value-based reimbursement system. A patient will provide their health information through an easy-to-use Web-based portal, prior to the visit. Patient self-identified healthcare needs and symptom acuity will allow a planned, individualized clinic visit by a healthcare team. Each visit will focus on keeping the patient healthy through performing basic and complex diagnostics, minor surgical procedures, prescribing by mid-level practitioners, and life-checks (ie, My Life Check: Live Better with Life’s Simple 7).8 Each visit will be devoted to following the 4 “P’s” of 21st century healthcare delivery: personalization, prediction (of disease), prevention and disease preemption, and patient responsibility.9 
 
Pharmacists are well positioned to be providers of primary care. Projected graduation rates of pharmacists in 2015-2016 appear to be sufficient to fill the projected 9% fall in primary care clinicians by 2020.5,10 Pharmacists have the education and training in basic pathophysiology, physical assessment, basic and complex diagnostic testing, pharmacotherapy, diagnosis of ailments requiring nonprescription medications, information technology systems, and wellness services, making them valuable to primary care. Collaborative practice agreements are in place in 47 of 50 states.11 Pharmacists can legally immunize adults and children in all states.12 Pharmacists are well trained to provide chronic care management--including disease state patient education and associated medication non-adherence and preventative care counseling. Pharmacists have demonstrated improved outcomes when compared directly to physician-driven standards of care.13-16 Pharmacists have also shown achievement of improved outcomes compared with physicians in the provision of patient self-care education .17 
 
Why should providers, healthcare industry, pharmacy community, and pharmacy educational academy adopt primary care pharmacists? First, the critical need for primary care practitioners has not been available since the 1960s when nurse practitioners were designed to meet the breach. This opportunity may never again be placed before the profession. It becomes imperative that the entire profession plan strategically and with expediency. Pharmacists have the education, skills, and talent to provide primary care services. Pharmacy education costs are currently unstainable in the current job market with graduating ratio of educational debt-to-income over 100%.4 Pharmacy graduates must have the opportunity to increase income to offset this debt. If pharmacy graduates do not have the ability to increase their income over their career, then why choose a career in pharmacy? Providing the potential for income growth through pharmacist-provided primary care services would serve to sustain recruitment of the best and brightest minds. Projected reduction in the dispensing workforce with an increase in clinical services have been stated for almost a decade.18 This projected decline in dispensing positions is not yet apparent because of the medication needs of the baby boom generation. There are several factors that suggest this may not occur in the near future. Consumers are demanding more of a HIT-driven access to healthcare, which has increased demand for mail-order pharmacy services. Physician-based dispensing practices are increasing. Importantly, the high rate of prescribing medications for the baby boom generation will subside by attrition, leaving a pending job crisis. If the profession moves towards primary care pharmacist practice, then future graduates will enter a growing, clinically based job market. 
 
Primary care is central to healthcare in the United States. An opportunity exists for pharmacists to assume a primary care role. Only through a unified coalition of professional organizations that share a vision for the advent of primary care pharmacists will we realize this opportunity. May we succeed in seizing this moment!