Expansion of Primary Care in a Post-COVID-19 World

If there has ever been a time in history that highlights the enormity and burden of healthcare challenges, it is amid this COVID-19 pandemic. With provider resources stretched to the limits, logistical challenges halting delivery of some supplies and declining revenues leading to layoffs, the pandemic has become the perfect storm to showcase problems within the healthcare system. Indeed, the industry is now forced to rebuild, reconsider and recalculate quickly to keep pace with patient demands. And for primary care settings, this translates to expansion. 

To overcome familiar stresses of complicated billing structures and provider shortages, the healthcare industry is looking for new options and opportunities that enhance capabilities and care offerings to reach a wider demographic. How? With 90 percent of Americans living within five miles of a pharmacy¹ and within 15 miles of a major big-box retailer, stores such as Walmart, Walgreens and CVS are expanding their scope beyond the pharmacy and into primary care services. Community-based and easily accessible, these retailers may be poised to assume a new role in the future of care, both in-person and via telemedicine.

Location, Location, Location 

With the spread of COVID-19 and the need for increased physical distancing, the location to receive care has become a great concern, and now provides a great opportunity. Fairly quickly, the option of telemedicine services became the new normal, and may prevail, particularly for those with transportation, ambulatory and time challenges. Provided patients have access to a reliable Internet connection and mobile device, a primary care option could be right at their fingertips, either with their current trusted provider or via a new care team through one of the many telemedicine organizations.

Of course, not everyone is interested or able to take advantage of telehealth. Some prefer in-person consultations, even if they are outside of a traditional healthcare setting. For instance, a Journal of the American Medical Association study found patients actively access healthcare services twice as often in community pharmacies versus primary care facilities, particularly in smaller and isolated communities where hospitals and other primary care settings are hard to reach. According to the study, pharmacists working as educators and coaches are efficacious in influencing community outcomes, including improved immunization rates, smoking cessation rates and lowered cardiovascular disease risks. Their care has also shown to positively influence improved lung function in patients with respiratory conditions and reduced hospital readmission rates in patients with heart failure.²

In the early days of the pandemic, the Centers for Disease Control and Prevention (CDC) urged retailers providing pharmacy services to do whatever was necessary to stay open and serve the public, and they did, providing medication counseling, addressing overall health concerns, supporting self-care and, importantly, offering a line of communication between patients and providers. Now, as COVID-19 vaccines are being administered, CDC estimates the vaccination timeline could improve by seven weeks and cover 80 percent of Americans with the inclusion of pharmacies as part of the distribution model.¹

In a system where primary care resources are strained, expanding the model of healthcare into big box settings can help fill gaps and provide good options for helping patients seeking preventive services and chronic disease management. Particularly in rural settings and underserved communities, big-box stores with healthcare services and pharmacies may offer patients their only opportunity to have regular healthcare visits. By locating these services in a familiar location and one in which patients would be frequenting anyway, their chances of proactively seeking care and managing their health increases, potentially reducing the burden on the larger healthcare system. 

In some big-box retailers, pharmacists already play the role of health and pharmacologic counselor, immunizer and educator, so an expansion of care seems a natural fit. With approximately 50 percent of U.S. adults having one or more chronic disease, 80 percent of whom are treated with prescription drugs, pharmacists are vital to long-term management of healthcare concerns. 

As healthcare expands further into big box retailers, staffing will also expand to include primary care physicians, physician assistants and certified nurse practitioners, all of whom work collaboratively to diagnose, treat, prescribe and refer patients to specialty care as needed. Walmart Health is one example, with health centers expanding into communities with limited preventive care options. CVS HealthHUB is also expanding its pharmacy services with Minute Clinics and educational programming. In many cases, these retail healthcare settings offer both in-person and telemedicine options for a set fee that is disclosed to the patient up front, regardless of the patient’s insurance, facilitating a transparent pricing model. 

Overcoming Financial Barriers to Care

Pharmacies served communities faithfully with “lights on, doors open,” according to National Association of Chain Drug Stores (NACDS) President and CEO Steven C. Anderson in the early days of the pandemic; however, their pharmacologic services still fight government bureaucracy that can hinder effective patient care. 

As an example of bureaucratic roadblocks, the Centers for Medicare and Medicaid Services does not recognize pharmacists as healthcare providers, thus making them ineligible for merit incentive payment systems. Yet, the critical services pharmacists offer extend well beyond dispensing and inoculating since they can and do work as part of a multi- and interdisciplinary healthcare team in support of providers’ and patients’ goals. Even so, with few exceptions, thanks to a negotiated fee-for-service payment model, much of the support provided by pharmacists is not billable. 

While providers are striving to serve patients against a sea of complicated and limited billing structures, with one demonstration of the financial benefits of clinical pharmacology can be extrapolated to community pharmacies. For instance, the Veterans Administration reports a $4 cost benefit for every $1 in clinical pharmacology services invested.³ Still, most insurance plans do not offer a designation code for billing many pharmacy services, even though Medicare Parts B and D allow for the administration of influenza and pneumococcal vaccines. These fee-for-service payments, which many argue prioritize volume over value, are in the early stages of change. Collaborative drug agreements that allow physicians to authorize pharmacists to oversee drug therapy for certain patients is one example that allows participation in a performance-based model of care that can be evaluated based on quality metrics.⁴

Patients are also concerned about rising costs and lack of predictability in pricing for their healthcare services, including reimbursements for prescription drug programs. One benefit for many in big-box healthcare settings is upfront fee disclosures, which patients can use to determine whether to pay for services out of pocket or go through their insurance provider. 

But, it’s not just primary care being incorporated into big box healthcare models. Wellness and prevention programs offer expanded opportunities for health education, nutrition services and support groups. Increased educational opportunities could be the boon needed to encourage engagement in those with historically limited access or interest in health improvement programs. CVS HealthHUBs, for instance, advertise meeting space for community-based programs. “We have a sense of urgency about the need to bring real change to healthcare,” says Kevin Hourican, executive vice president of CVS Health and president of CVS Pharmacy. “What’s clear to us is that it will take more than incremental steps to fix what is broken in the healthcare system.”⁵

Roadmap for the Future

Whether pharmacists work alongside providers as part of a comprehensive care team or providers practice under the shingle of big-box retailers or via telemedicine, patient care enhancement involves moving away from silos and toward accessibility, including enhanced data management.⁶

A Deloitte survey of U.S. physicians from Jan. 15, 2020, to Feb. 14, 2020, recommends shifting focus toward patient empathy, well-being and prevention services that support delaying and averting diseases and envisions a future in which a clinician’s “training and culture-building department … is bigger than their coding department.” 

And, core educational competencies outlined in the Institute of Medicine’s Health Professions Education: A Bridge to Quality stress the utilization of patient-centered care in which needs are addressed through interdisciplinary teams. According to the book, to better serve patients, improved sharing of pertinent information among patients and providers, and between care teams, is being discussed.

According to the Deloitte survey, the industry can accomplish these goals through greater use of data-driven technology and expanded capabilities that support a collaborative healthcare team approach. As an example, pharmacy information technology systems may limit capabilities and patient discussions due to lack of synergy with the larger electronic health record system. Additionally, patients are taking an increasingly active role in managing their own health data, so much so that 65 percent of physicians expect consumers will own and control their own data within five to 10 years and become a greater part of the equation.⁶

With the U.S. Bureau of Labor and Statistics anticipating an increase of 14 percent in the number of healthcare worker jobs,⁷ now is the time to rethink how and where healthcare is being delivered. Meeting patients where they are, both literally and figuratively, ensuring a supportive structure of care that addresses the whole patient, and conveying information in such a way that patients are capable and motivated to take ownership of their own outcomes provide the best chances for success. 

In the end, whether in a pharmacy, big-box or traditional healthcare setting, an ability to ask intuitive questions, hear the answers and integrate that information across data points ensures patients are the ultimate beneficiaries. As the U.S. healthcare system returns to normal, a new normal is on the horizon, one that expands options for patients, caregivers and the future of care.