The Time for Pharmacists to be “Essential” in Primary Care is Now: Part 1

There are multiple factors coming together that support pharmacists becoming “essential” in primary care.  Perhaps the most important is the COVID-19 pandemic for which several persons have written commentaries on the importance of pharmacists in the COVID-19 crisis.  Specifically, the United States Health and Human Services granting pharmacists the ability to order and administer COVID-19 testing.^1-3 Multiple data recognize the need and opportunity for pharmacists to participate in primary care throughout the United States (US). 

This is a three-part series on the opportunity, changes needed in pharmacist education and practice, and how to become essential in primary care.  The first part discusses the current status of US physician supply and demand, primary care spending in the US, and health consequences of primary care delivery.   

Physician/Nursing Shortage in the U.S. 

The Association of American Medical Colleges (AAMC) published an annual report entitled “The Complexities of Physician Supply and Demand: Projections From 2018 to 2033.⁴ It is important to note that the 2020 update was published before the COVID-19 crisis.  A second important note is that demand projections start with the assumption physician supply and demand are currently (in 2018) in equilibrium-except for primary care.  Given these assumptions, the AAMC report states that there is a primary care physician shortage of 21,400 to 55,200, projected by 2033.  Why?  The shortage is due to growth the US population by 10.4% from 327 to 361 million persons.  Much of this growth will be in the population age ≥ 65 years projected to grow by 45.1%.  This increase in the geriatric population means the continued need for elderly care including prescriptions will continue to remain strong.  The second important point is a large portion of the physician workforce is nearing retirement age.  Approximately 1 in 5 active physicians will be ≥ 65 year olds within the next decade.  Lastly, if the underserved populations were availed of health care similar to urban and suburban populations with fewer access problems, the physician shortage will become more acute.  

Nursing is also projected to experience a shortage of practitioners.  Although registered nursing is currently undergoing job growth, the projections are an additional 200,000+ nurses will be needed by 2026 to fill newly created positions and to replace retiring nurses.⁵ 

Primary Care Spending in the US 

Fewer primary care physicians may also be due to flat primary care spending in the US.  Total annual healthcare expenditures in the US increased from $810 billion in 2002 to $1617 billion in 2016.⁶ Primary care spending accounted for 6.5% of total expenditures without appreciable change throughout the study period.  In addition, fewer adult Americans have an identified primary care source.⁷ The number of adults with a primary care provider decreased from 77% in 2002 to 75% in 2015.  The decrease occurred in adults of every decade of age, except those in their 80s.  In particular, the greatest decrease in occurred among younger generations along with those who less medically complex.⁶   Male sex, Hispanic, Black, and Asian race/ethnicity, not having insurance, and living in the South were also factors associated with not having a primary care physician.   

Primary Care is Associated with Better Health. 

Primary care is associated with better health.  An epidemiological study evaluated US population data linked to mortality from 2005 to 2015 against changes in primary care physician supply.⁸ Data from 3142 counties and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality.  Greater primary care was associated with lower mortality.  For every 10 additional primary care physicians per 100,000 population there was a 51.5-day increase in life expectancy (95% CI: 29.5-73.5 days; 0.2% increase).  For comparison, an increase in specialist physicians was associated with a 19.2-day increase (95% CI: 7.0-31.3 days).   

Receipt of primary care was studied a nationally representative sample of noninstitutionalized US adults 18 years or older who participated in a Medical Expenditure Panel Survey.⁹  Propensity score-weighted quality and experience of care was compared between 49,000+ adults with and 21,000+ adults without primary care from 2012-2014.  Primary care was determined by patient-reported receipt of primary care through acknowledgement of the first-contact care that was comprehensive, continuous, and coordinated.  Receipt of primary care was associated with significantly more high-value care (i.e., cancer screening), along with better access, experience, and communication.   

To summarize, there is a decreasing proportion of physicians, especially in primary care.  This maybe, in part, due to a flat curve of primary care spending in the US for over a decade.  The result, is fewer Americans have self-identified primary care physician—most acute in younger, less medically complex, and minority backgrounds.  The lack of primary care physicians results in less primary care visits resulting in poorer health and potentially higher mortality. 

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy. 

References:

1. Pharmacists respond to COVID-19: An Army of Experts Needed. https://www.pharmacypracticenews.com/Covid-19/Article/04-20/Pharmacists-Respond-to-COVID-19--An-%20Army-of-Experts-Needed/57892  Accessed 09/2020
2. HHS Allows Pharmacists to Provide COVID-19 Tests. https://www.policymed.com/2020/04/hhs-allows-pharmacists-to-order-and-administer-covid-19-tests.html  Accessed 09/2020
3. Pharmacists are on the Front Line of COVID-19, but they need help too. https://www.pharmaceutical-journal.com/news-and-analysis/opinion/editorial/pharmacists-are-on-the-front-line-of-covid-19-but-they-need-help-too/20207829.article?firstPass=false  Accessed 09/2020
4. The Complexities of Physician Supply and Demand: Projections from 2018 to 2033. https://www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf    Accessed 9/2020
5. Nursing Shortage: https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage Accessed 09/2020
6. Martin S, Phillips Jr. RL, Petterson S, Levin Z, Bazemore AW. Primary care spending in the United States 2002-2016. JAMA Intern Med 2020; 180(7):1019-1020. doi:10.1001/jamainternmed.2020.1360
7. Fewer Adults Have Dedicated PCP. https://www.managedhealthcareconnect.com/content/fewer-adults-have-dedicated-pcp?hmpid=bW11bmdickBOc2MudXRhaC51ZHU  Accessed 09/2020
8. Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of primary care physician supply with population mortality in the United States, 2005-2015.
9. Levine DM, Landon BE, Linder JA. Quality and experience of outpatient care in the United States for adults with and without primary care. JAMA Intern Med 2019;179(3):363-72.