What is advanced primary care (APC)?

Put simply, advanced primary care is a newish model of delivering value-based primary care to patients (generally on a per member per month basis) that focuses on quality, affordability, and improved health outcomes and is more collaborative and comprehensive in nature than traditional fee-for-service models. Advanced primary care teams often consist not only of physicians, nurse practitioners, physician assistants, nurses, and medical assistants, which have been the conventional makeup of primary care clinics – but also nutritionists, behavioral/mental health counselors, wellness coaches, social workers, and transportation coordinators. This innovative model is also referred to as the patient centered medical home, primary care medical home, or healthcare home.

The current primary care physician (PCP) shortage is expected to worsen

According to the Association of American Medical Colleges (AAMC), the US is expected to face a shortage of PCPs ranging from 21,400 to 55,200 by 2033.₁ While nurse practitioners and physician assistants who go into primary care practice may help bridge that gap, many states are still lagging far behind in passing progressive legislation to enable these mid-level providers to practice autonomously (via full practice authority) in the ways they are needed in their communities. It’s all too commonplace to see PCPs running behind in seeing patients each day in their practices because they are performing tasks that other care team support is better equipped to do. Examples of these tasks that clinic-embedded pharmacy personnel can absorb and complete successfully include prescription prior authorization management, medication therapy management, medication reconciliation, in-depth medication and disease state counseling, ordering lab tests, and approving refill authorizations. And with the recent expansion of telehealth visits and remote chart review, leveraging clinical pharmacists and technicians to navigate this work behind the scenes will be minimally disruptive to on-site clinic operations.

The aging population is rapidly changing America’s demographics

According to statistics published by the Rural Health Information Hub, by 2030, 1 in 5 Americans is projected to be 65 years old and over. Put another way, between 2020 and 2030, the number of older adults is projected to increase by almost 18 million to around 64 million. Much of this population (approximately 1 in 5) resides in rural communities, which are already disproportionately negatively impacted by limited primary care access.₂ If these percentages stay the same, this will add 3.6 million new seniors to rural areas already under-resourced in primary care providers. And given that almost 3 out of 4 people age 65 and older have multiple chronic conditions, this population will continue to be a high utilizer of the healthcare system, in particular with regard to prescription drugs, supplements, and over the counter (OTC) medications. Nearly 90% of adults 65 and older currently take at least one prescription medication, with more than 50% reporting they take 4 or more prescription drugs.₃ Pharmacist expertise around polypharmacy, renal and hepatic dose adjustments, drug-drug interactions, drug-disease interactions, adherence counseling, deprescribing, and transitions of care are of paramount importance in keeping seniors healthy in rural and urban communities alike and therefore should play an integral role in the holistic care that advanced primary care systems espouse.

Pharmacists’ “provider status” is gaining steam – a matter of time

Pharmacists have long stood in healthcare gaps and done whatever is necessary to ensure improved patient access and outcomes – we just haven’t been paid (or have been grossly underpaid) for those services. But those days do appear to be slowly coming to an end, with state and federal legislation in motion to recognize pharmacists equitably as healthcare providers who can bill health plans for patient care services rendered within our scope of practice. These services fall outside of dispensing medications and include chronic disease management, immunizations, disease/health screenings, point-of-care testing, and medication management. One of the ripples that this long-awaited recognition should cause is to enable/empower companies providing primary care to reimagine their service models and be more inclined to integrate pharmacy personnel into their workforce. Not only does it make sense from improved patient outcomes, interprofessional workload sharing, and cost savings perspectives, it will become revenue-generating in much more tangible, measurable ways. While there may continue to be barriers to getting federal legislation passed, pharmacists credentialed with payers, medical claims paid at higher rates, etc. for the next few years, there are still compelling patient-centered reasons for advanced primary care models to become early adopters now.

The value-based APC model is a much-needed departure from traditional fee-for-service payment structures that have led to the United States healthcare system being more of a place for providing ineffective and expensive “sick care”. It’s encouraging to see the patient centered medical home approach is progressing as more big-name self-funded companies are examining ways to contain ballooning healthcare costs, particularly around medication management and caring for members living with complex chronic conditions. However, for this model to enjoy long-term success and become a mainstay in redefining how we deliver primary care to patients, a necessary evolutionary step will be to integrate pharmacy practice expertise sooner versus later.

Creating the framework for clinical pharmacy services is a complex and time-consuming endeavor, albeit incredibly worthwhile. I’m hopeful that companies on the cutting edge of the advanced primary care model will engage now with pharmacy practice leaders and partner together on defining pharmacy’s role in delivering comprehensive, outcomes-based quality healthcare. Start small, find the lowest hanging fruit that will yield return on investment for your patient population, and work out the bugs so the program will be scalable when it makes economic sense to do so.

References:

1. The Complexities of Physician Supply and Demand: Projections From 2018 to 2033. (2020, June). Association of American Medical Colleges. https://www.aamc.org/media/45976/download
2. U.S. Census Bureau. (2015, March). Demographic Changes and Aging Population. Www.Ruralhealthinfo.Org. Retrieved March 22, 2022, from https://www.ruralhealthinfo.org/toolkits/aging/1/demographics#:~:text=Today%2C%20there%20are%20more%20than,increase%20by%20almost%2018%20million
3. Kirzinger, A., Neuman, T., Cubanski, J., Brodie, M. Data Note: Prescription Drugs and Older Adults. (2019, August). KFF. Retrieved March 22, 2022 from https://www.kff.org/health-reform/issue-brief/data-note-prescription-drugs-and-older-adults/#:~:text=Prescription%20Drug%20Use%20and%20Affordability,%25)%2018%2D29%20year%20olds