THE COVID-19 PANDEMIC has laid bare many of the flaws in our country's health care system, including a weak public health infrastructure, the terrible and persistent health and health care disparities experienced by people of color and other marginalized populations, our inability to nimbly redistribute vital equipment and human resources, the consequences of chronic underfunding of long-term care, and the utter absence of a functional collaboration between policy makers and the health care delivery system. In addition, the very design of how we deliver health care, who delivers it, and how it is compensated is exposed as inadequate, not only in the context of the pandemic but also for meaningful impact on the things we consider most important for the health of our citizens—primary care, preventive care, mental health, and social determinants of health.
In their article on pharmacists as frontline responders during Covid-19, Thiessen et al describe a number of roles for pharmacists in ambulatory primary care that have become more available as resources and flexibility have been paired to allow for more innovation in response to the pandemic. In my 34 years as a family physician in rural Maine, first in solo practice and then with federally qualified health centers (FQHCs), as the nature of primary care has become more complex and we have properly moved to include population health as a key responsibility, this now widely held perspective has become more and more evident: patient-centered primary care should be delivered by a team of professionals with complementary expertise and skills. During the years that I have served as Chief Medical Officer of Maine's largest FQHC, I have had the privilege of working with and learning from primary care pharmacists. In our organization, they provide patient disease education, manage anticoagulation, lead and coordinate primary care–based treatment of hepatitis C, play pivotal roles in antibiotic and controlled substance stewardship, have been important members of opioid use disorder treatment teams, participate in morbidity and mortality reviews, and, of course, provide medication consultation. Pharmacists' training and knowledge base are almost perfectly complementary to that of a primary care provider and their participation as a full member of our primary care teams has helped improve quality metrics, patient experience, and provider satisfaction. In rural settings, where recruiting and retention of primary care physicians, nurse practitioners, and physician assistants remain the most important health care challenge, the benefits of this partnership should be self-evident. Yet, payers in Maine and in many others fail to recognize pharmacists as providers and without alternative funding streams (eg, 340B revenue in an FQHC, robust pay-for-performance incentives paired with a track record that ensures adequate revenue); funding for ambulatory care pharmacists is simply unavailable to most primary care practices, and this resource cannot even be contemplated in rural settings. During this pandemic and afterward, we must rethink our approach to health and health care. Ambulatory care pharmacists as colleagues and partners in primary care will help us provide better care for more people and will help us build and maintain more stable primary care teams in the communities with the greatest need for our services. But hard-pressed primary care settings will need a financial bridge to this new model. Primary care should be compensated relative to its impact on outcomes, but our current system values high-cost interventions for treatment of disease complications much more highly than preventive care or the proper management of chronic disease. Absent a shift in that dynamic, pilot programs of robust total cost of care reimbursement for primary care, greater incentives (and risk) in value-based purchasing models, or grant-supported studies of this model in rural settings with rapid dissemination strategies can accelerate much needed progress for the people and communities in most dire need.