In this research, the varying and expanding roles of pharmacists in the United States are explored. These expanding roles position pharmacists to have greater impact in the shifting landscape of health care and public health. Beyond the most widely accessible role of medication dispensing, pharmacists’ engagement in patient care includes a consultative role whereby they fill in gaps in clinicians’ knowledge, and collaborative and integrative roles in settings such as patient-centered medical homes through formal agreements. However, pharmacists’ services vary depending on the setting and state scope-of-practice laws. At the same time, research evidence shows the effectiveness of engaging pharmacists as part of the direct patient care team. It is believed that improving patient awareness of these potential roles would help to more effectively incorporate them into a greater number of health care teams and lead to improved patient outcomes and safety.
Number of Pharmacists by Setting
- According to the U.S. Bureau of Labor Statistics (BLS), for the 321,700 pharmacist jobs in 2019, the main work environments are:
- Community pharmacies/drug stores — 42%,
- Hospitals (state, local, private) — 26%, and
- Commercial retail stores such as food and beverage stores (8%) and general merchandise stores (5%).
- On the other hand, an October 2019 report by the National Association of Boards of Pharmacy (NABP) estimates a total of 387,000 licensed pharmacists in the U.S.
- Meanwhile in July 2019, the Board of Pharmacy Specialists revealed that there are 42,710 licensed pharmacists with active specialty certifications. According to their website, these specialty certifications and the number of board-certified pharmacists include:
- Ambulatory Care — 4,342
- Cardiology — 319
- Compounded Sterile Preparations — 435
- Critical Care — 2,579
- Geriatrics — 4,674
- Infectious Disease — 854
- Nuclear Pharmacy — 400
- Nutrition Support — 672
- Oncology — 3,197
- Pediatrics — 1,182
- Pharmacology — 26, 077
- Psychiatric — 1,270
- These certifications indicate that the pharmacist has obtained “additional knowledge, experience, and skills in a defined area of pharmacy practice”, allowing them to expand their services to certain patients.
1) Widely-Accessed Services
The most widely accessed services offered by pharmacists, according to the literature, are medication dispensing, medication therapy management (MTM) and chronic disease management.
- The most frequently acknowledged role of pharmacists is medication dispensing.
- Medication dispensing refers to the preparation and packaging of medications for patients based on a prescription from a health care provider, including patient counseling on appropriate use.
- It is the pharmacist’s job to ensure that the recommended prescription will be safe for the patient, especially regarding other drug use and potential interactions.
- The approximately 118,000 full-time pharmacists at pharmacy chains such as Walgreen and CVS are responsible for filling 72% of prescriptions in the United States annually.
Medication Therapy Management (MTM)
- As of January 1, 2006, pharmacists became eligible to provide new medication therapy management (MTM) provisions under Medicare Part D as a prescription drug benefit for those older than 65 years old.
- MTM involves the continual monitoring of medications for patients with chronic illnesses such as diabetes or high blood pressure.
- Multiple studies have found that allowing pharmacists to offer this type of patient care has resulted in enhanced medication adherence and reduced hospital admissions.
- According to the CDC, expanding the pharmacist’s role through MTM is likely to increase access to health care for populations facing the most barriers to care since nearly nine in ten persons live within five miles of a community pharmacy.
- MTM services can be delivered in person in various health care settings (community pharmacy, clinic, primary care practice, hospital, ER) as well as remotely by phone and video chat.
Chronic Disease Management
- Pharmacist-led chronic disease management is a special type of MTM that expands to include the management of medication needed for more than one disease such as asthma, diabetes, etc.
- In this case, pharmacists aid in managing multiple prescriptions received from multiple providers by serving as a central source of information and looking for contraindications across medicines.
- Studies have shown that this type of pharmacist-led intervention in hospital settings had similar effects to those of usual provider care for resource utilization but improved physiological goal attainment among patients.
2) Lesser-Known Services
The services in this part of the research appear to be lesser-known to the public, according to the literature. This is because broad access to patient care services delivered by pharmacists is controlled by policy and compensation barriers. They include the specialty certified pharmacists described above, collaborative practice agreements (CPAs), the administration of vaccinations, transition of care and general patient education.
Collaborative Practice Agreements (CPAs)
- A 2019 report by the National Alliance of State Pharmacy Associations confirmed that 33 states allow any licensed pharmacist, in any practice setting, to participate in a Collaborative Practice Agreement (CPA).
- CPAs are a formal agreement that allow pharmacists to work alongside physicians to provide expanded direct patient care through comprehensive disease management.
- Research indicates that when patient care services are provided by pharmacists through these agreements, it can reduce fragmentation of care, lower health care costs, and improve health outcomes.
- It should be noted that while CPAs are not in themselves a service offered by pharmacists, they facilitate the expanded services a pharmacist can provide to patients and the healthcare team such as the previously discussed medication therapy management.
Administration of Vaccines
- In general, state laws governing pharmacists’ authority to vaccinate depend on the type of vaccination, the route of administration, and the age of the patient. Based on these criteria many states allow for the use of protocols and standing orders, while some require prescriptions from a physician before pharmacists may administer certain vaccines to particular aged patients.
- Currently, 48 states allow community pharmacists to administer any vaccine through various processes. These vaccines include Hepatitis B, Rotavirus and Varicella. All 52 states allow pharmacists to administer pneumococcal vaccine, zoster vaccine, influenza vaccine and tetanus-diphtheria vaccine.
- However, since patient age also controls the pharmacists’ authorization to administer these vaccines, the following regulations hold:
- 27 states allow pharmacist-administered vaccinations for patients of any age.
- 34 states allow pharmacist-administered vaccinations for patients 18 years or older.
- only 18 states allow pharmacist-administered vaccinations at different age levels from 3 years to 14 years.
- Although 73% of community pharmacists offer immunizations, CDC’s early 2017 estimates indicated only 28% of adults and 4.9% of children received influenza inoculations at a pharmacy or store.
- However, a survey of patients found that they prefer receiving vaccinations in a pharmacy compared with a more traditional environment because of the convenience — no appointment necessary, shorter waiting times and no out-of-pocket pay for the visit.
Transition of Care
- Pharmacists may be involved in the transition of care when patients are changing settings, for example, being discharged after surgery or hospitalization.
- In this type of service, pharmacists may form part of the healthcare team to coordinate care between providers at the different settings (such as physician and family). Their expanded roles in care transitions include participation on medical rounds where available, transition counseling, medication reconciliation and admission drug histories, and involvement in medication adherence.
- The pharmacist expanded role in the transition of care is subject to available reimbursement mechanisms but studies show that their involvement can lead to lowered readmission rates especially due to greater medication adherence.
General Patient Education
- Pharmacists can be considered the most accessible health care providers. On average, U.S. patients visit a pharmacy 35 times a year compared with just 4 visits to medical providers.
- Additionally, in today’s changing world, patients want and expect convenience including from their care providers. This results in more care being sought in community locations where the majority of pharmacists work.
- However, current literature shows that few persons are familiar with pharmacists’ roles in engaging patients in health promotion and disease prevention.
- Beyond specific drug intake information, depending on state regulations, pharmacists may educate patients on smoking cessation aids, provide hormonal contraception, and screen for disease through blood pressure and other point-of-care tests.
- Pharmacists can also assist patients with managing costs and navigating health insurance coverage. They can suggest alternative, low-cost generic medications or over-the-counter options when available to reduce patients’ out-of-pocket price points.
Special Case — U.S. Opioid Addiction Epidemic
- A pharmacy presence on national, state, and local levels is helping to address the opioid epidemic. As of January 2019, all states allow pharmacists to “dispense or distribute naloxone without a patient-specific prescription from another medical professional.”
- Due to the dire urgency of the opioid epidemic in the United States which in 2019 alone was responsible for 71,000 deaths, “pharmacists are beginning to be embedded in addiction clinics, in medication-assisted treatment clinics, where pharmacists there are helping to initiate suboxone, and also doing a lot of the monitoring of that process as well.”
- Furthermore, pharmacists can also play a role in educating both the patient and other health care providers about non-opioid pain treatment options to reduce the potential of addiction.
- However, expanding pharmacist roles to be involved in patient opioid addiction treatment teams relies on legislation that allows pharmacists to bill for these services.
3) Expanded Services due to COVID-19
- According to the CDC, community pharmacists are in a key position to deliver priority pandemic responses including point-of-care testing for chronic disease management, vaccinations, and COVID-19 testing, especially as the health care system was overtaken by COVID-19 cases.
- The pandemic has highlighted the important role that community pharmacists make during an infectious disease outbreak. In rural areas or areas with higher concentrations of people of lower socioeconomic status, pharmacists have been able to effectively and safely maintain patient access to essential medicines through curbside pickup, larger refill quantities, and home delivery.
- Hospital pharmacists contribute to COVID-19 management protocols by participating in inpatient rounds, ensuring sufficient medication supply to support ICU beds while managing critical drug shortages through the implementation of conservation strategies and sourcing alternatives.
- Additionally, pharmacy advocates suggest that preparedness efforts for future outbreaks need to begin well in advance of a crisis, with pharmacists being fully integrated in preparing for an emergency in order to ensure efficient delivery of public health resources.
Novel Disease Testing and Vaccinations
- More than 10,000 pharmacies already perform Clinical Laboratory Improvement Amendments (CLIA)-waived tests to detect influenza and streptococcal pharyngitis and to monitor chronic diseases through a wide range of CLIA-waived point-of-care testing.
- As a result, these pharmacies were already authorized and prepared to incorporate COVID-19 testing into their workflow.
- As the pandemic rages on, community pharmacists and pharmacies can provide ongoing COVID-19 surveillance through walk-in testing. This is expected to be more sustainable and convenient than the large-scale public screening that was initially done.
- The US Department of Health and Human Services has authorized all pharmacists to provide these COVID-19 testing services, overriding state law where it exists while the Centers for Medicare and Medicaid Services (CMS) is reimbursing pharmacies for this COVID-19 testing.
- It is also expected that community pharmacists will play a key role in the wide-scale administration of a vaccine for the COVID-19 virus once it is available, making it widely accessible in convenient and familiar locations.
Routine Vaccine Administration to Children
- An August 2020 Department of Health and Human Services (HHS) decision now allows pharmacists to administer routine vaccinations to children during the COVID-19 pandemic.
- According to Alex Azar, the HHS Secretary, the expanded authorization is meant to maintain high immunization rates during the pandemic through easier access and allowing pharmacists to practice at the top of their license.
- The declaration was filed as an amendment under the Public Readiness and Emergency Preparedness Act related to COVID-19, and overrules state laws for as long as the public health emergency exists.
The Positive Impact of Pharmacists on Healthcare
Leading medical advisers at the Centers for Disease Control and Prevention have definitively stated that expanding the role of pharmacists can lead to increased quality of care, improved patient control of disorders and illnesses, and reduced healthcare costs. Furthermore, pharmacist-provided services and clinical interventions have been proven to reduce the risk of potential adverse drug events and improve patient outcomes as a result of the increasing number of pharmacists who have been allowed to work in clinically advanced roles. These positive impacts have been demonstrated through the results of numerous studies, some of which are highlighted below. It should be noted that the research included older studies (more than 10 years) if they provided detailed statistics or metrics that measure the positive impact of expanded pharmacist-provided services.
1. Improved Patient Outcomes
- According to a recently published comprehensive review of 298 studies by the University of Washington’s Center for Health Workforce Studies, patient outcomes, such as cholesterol levels, blood pressure, and adverse drug events, significantly improved when pharmacists were involved in direct patient care as opposed to conventional or alternative care.
- Recently published research conducted by health associates at the University of Wisconsin looked at the impact of having pharmacists act as patient care extenders for chronic disease management. The results show:
- Blood pressure control to less than 140/90 mmHg (above which is considered high blood pressure) was achieved in 74.15% of patients who engaged with primary care pharmacists versus 41.53% of eligible patients electing to follow usual care pathways, and
- Appropriate statin (class of drugs used to lower cholesterol levels in the blood) was higher in patients engaged with primary care pharmacists than in eligible patients electing to follow usual care pathways both for diabetes and ischemic vascular disease (12.4% and 2.2% higher, respectively).
- In 2008, a survey of physicians who had entered into Collaborative Practice Agreements (CPAs) with pharmacists found a whopping 96% of respondents attesting to multiple benefits including improved disease management outcomes and reduced burden on primary care providers who could fit more critical patients into their schedules.
- A systematic review of data from 1998 MedPAR, American Hospital Association’s Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, involving 2,836,991 patients, examined the relationship between hospital-based clinical pharmacy services and mortality rates. The data showed that the implementation of the following seven clinical pharmacist-provided services at hospitals were definitely associated with lower mortality rates:
- Drug use evaluation (4491 reduced deaths),
- In-service education (10,660 reduced deaths),
- Adverse drug reaction management (14,518 reduced deaths),
- Drug protocol management (18,401 reduced deaths),
- Participation on the cardiopulmonary resuscitation team (12,880 reduced deaths),
- Participation on medical rounds (11,093 reduced deaths), and
- Admission drug histories (3988 reduced deaths).
- This study would have been used to support the expansion of clinical pharmacy services across the United States after it was published.
2. Patient Safety
- Studies have shown that 66% of adults take five or more drugs per day while 27% take 10 or more per day, making a pharmacist’s work in promoting the safety and well-being of patients more important than ever before.
- A recent Canadian study conducted over four years with patients 65 years or older found that a pharmacist-led educational intervention was successful in deprescribing “risky” medications in 43% of those enrolled in the study, compared to only 12% of patients who did not receive pharmacist intervention.
- It should be noted that deprescribing becomes necessary because of disjointed healthcare systems where many prescribers are unaware of medications a patient may be taking that have been prescribed by another member of the patient’s healthcare team, potentially leading to harmful combinations and adverse effects.
- A 2014 study in JAMA Internal Medicine found that when pharmacists directly distributed educational materials to reduce inappropriate benzodiazepine (tranquilizers such as Valium and Xanax) prescriptions for older people, it was successful 27% of the time versus 5% in usual care.
3. Reduced Healthcare Burden — Fewer Visits
- At the University of Southern California, a program was developed to allow pharmacists to oversee the post-discharge care of Medicaid patients at Kern Health Systems in Bakersfield, California. In the program, pharmacists monitored patients to ensure that they followed medication guidelines correctly, scheduled follow-up appointments, arranged meetings with specialists and helped patients who needed transportation assistance.
- A review of the program found that 30-day readmission rates declined by 28% and 180-day readmission rates by close to 32%.
- Another recently published study carried out through the University of North Carolina found that pharmacist intervention in care transitions in the ambulatory care primary care setting significantly reduced all-cause 30-day hospital readmission rates (9% versus 26% in usual care) and the composite endpoint of 30-day health care utilization, which is defined as readmission and emergency department (ED) rates (19% versus 44% usual care).
4. Cost Savings
- A long-quoted figure is nearly $300 billion — that is, the estimate of the cost of medication non-adherence annually in the United States, primarily as a result of hospital readmission rates.
- Medical non-adherence results in these costly readmission visits because it refers to the fact that almost 50% of all prescribed medications are not taken properly and nearly 25% are never started.
- The authors of the study responsible for the cost above found that improved medication adherence was associated with pharmacist-led high blood pressure management.
- A case study by Allina Health, a non-profit health system, on the effects of pharmacists performing medication therapy management (MTM) to a group of Medicaid patients discovered a $2,085 mean total cost of care reduction per patient in the six-month period after the first pharmacist encounter. This would mean a $590,000 cost savings over the 283 patients.
- Separate case studies from seven states that offer Medicaid-supported medication management (MM) programs have found that these pharmacist-led programs resulted in improved patient treatment goals and reduced hospital costs. Selected states and the outcomes are:
- Connecticut — a 28% increase in achievement of patients’ treatment goals and an estimated annual savings of $1595 per beneficiary in total health care costs,
- Minnesota — a reduction in medical and pharmacy costs of approximately $800 per MM recipient, and
- Maine — a decrease in hospitalizations from 114 to 96 at 6 months post-MM intervention and emergency department (ED) visits decreased from 384 to 347, as well as a decrease in inpatient hospitalization costs from $1,076,394 to $830,353.
Other Related Findings
The following findings are included as further evidence from reputable research publications to support the claim that expanding the role of pharmacists leads to a positive impact on the healthcare system, however, they do not include any discrete data points or statistics.
- A widely-cited 2002 study found that pharmacist-conducted medication histories were more accurate and resulted in cost savings as well as increased patient safety in hospitals.
- Although not based in the United States, a more recent study published in 2013 confirmed similar findings. It concluded that a pharmacist-acquired medication history in an emergency department reduced discrepancies that had the potential to cause moderate discomfort or clinical deterioration by 33%.
- The University of Washington’s literature review found the evidence showing that pharmacists can optimize medicine use, lower medication-related costs and improve overall efficiency in care when they work as partners on health care teams with patients and providers.
- The review also stated that shifting pharmacist roles to deliver more value-based and preventive care can reduce healthcare spending since current practices means pharmacists are largely reimbursed based on volume (i.e. dispensing more drugs results in higher revenue for the pharmacy).