Pharmacy’s role in population health
INNOVATION
By Zach Krauss, PharmD, MBA
Pharmacy innovation within the realm of population health has seen significant advances, particularly in how pharmacists contribute to improving health outcomes on a large scale. This area focuses on optimizing the management of chronic conditions, reducing health disparities, and ensuring medication safety and access across diverse populations. Within the realm of population health, pharmacy professionals are managing and improving, as the namesake implies, the overall health of entire populations. Pharmacists working in this field are able to make this impact by utilizing a combination of skills related to pharmacotherapy, patient education, and data management.1
Integration of pharmacists in population health teams
One of the most notable innovations in this space is the integration of pharmacists into interdisciplinary population health management teams. By working alongside physicians, nurses, social workers, and other health care professionals, pharmacists play a crucial role in developing and executing care plans tailored to population needs.1-2 They help manage chronic diseases like diabetes, hypertension, and asthma, which require ongoing medication management and adherence support. Pharmacists are often responsible for conducting medication therapy management (MTM) services, ensuring that patients are on the most effective, safe, and cost-efficient regimens.
In settings such as accountable care organizations and patient-centered medical homes, pharmacists provide direct care, including medication optimization, patient counseling, and monitoring for adverse drug reactions. These activities help prevent hospital readmissions and improve overall health care outcomes by ensuring that patients receive the right medications at the right time.
Value-based care models and incentives
Population health initiatives help health systems generate revenue by aligning with value-based care (VBC) metrics, which emphasize improving patient outcomes while controlling costs. By focusing on preventive care, reducing hospital readmissions, and managing chronic diseases, pharmacists and health care teams play a crucial role in meeting these goals. Effective medication management, patient education, and chronic disease monitoring lead to fewer costly hospital visits and better adherence to treatment plans, resulting in financial rewards through shared savings programs like Medicare’s Merit-Based Incentive Payment System and the Medicare Shared Savings Program.1-3 As gaps in care are identified for metrics—such as medication adherence, status use in patients with diabetes, vaccination history, etc.—pharmacists are then able to do targeted interventions aimed at these incentive-based VBC contracts.
Population health efforts are often closely tied to the Institute for Healthcare Improvement's Triple Aim, which focuses on improving patient experience, health outcomes, and reducing per capita health care costs. This makes population health a critical strategy for meeting VBC metrics.
Data-driven decision-making
The use of data and health informatics has also transformed pharmacy's role in population health. Pharmacists now leverage electronic health records and data analytics tools to identify high-risk populations who could benefit from targeted interventions. For example, using predictive modeling, pharmacists can pinpoint patients at risk of medication nonadherence, adverse events, or uncontrolled chronic conditions. This enables pharmacists to proactively intervene before health issues escalate, enhancing medication adherence and reducing the burden of preventable hospitalizations.1-3
Telepharmacy and remote care models
Telepharmacy has emerged as a critical innovation, especially in expanding access to care in rural and underserved populations. Through virtual consultations, pharmacists can provide medication counseling, chronic disease management, and MTM services to patients who may not have easy access to a physical pharmacy, especially because there is an increased number of “pharmacy deserts” where patients are not physically close to pharmacies that can assist them with medication management. Telepharmacy also supports population health initiatives by allowing pharmacists to monitor patients remotely, ensuring continued care without the barriers of distance or transportation.4
Additionally, remote patient monitoring tools enable pharmacists to track vital signs and medication adherence in real time, allowing for timely interventions. This technology-driven approach is crucial in managing large populations and addressing the health care needs of individuals who may face barriers to traditional care.
Pharmacy-driven health equity initiatives
Pharmacists are increasingly involved in addressing health disparities through targeted interventions. Population health efforts led by pharmacists often focus on improving access to medications and health care services in low-income, minority, and rural communities. By working with public health organizations, pharmacists can implement strategies to reduce gaps in care, such as providing discounted medications, establishing medication access programs, and delivering culturally competent care.1-3
Pharmacy innovation in population health is fundamentally changing the way health care is delivered to large, diverse groups. By integrating data, technology, and direct patient care, pharmacists are well-positioned to lead initiatives that enhance health outcomes and reduce costs across populations.
Zach Krauss, PharmD, MBA, is a PGY2 health-system pharmacy administration and leadership resident at Atrium Health Wake Forest Baptist in Winston-Salem, NC, and a member of the 2024–2025 APhA New Practitioner Network Communications Standing Committee. He is looking forward to working in health-system management in the ambulatory, infusion, or specialty space, and also has some clinical interest in the oncology space. Zach enjoys listening to and performing music, exploring new cities and trying new foods, and spending quality time with his co-residents and friends.
References
1. Center for Disease Control and Prevention Website. What is Population Health? Accessed September 17, 2024.
2. Strand MA, DiPietro Mager NA, Hall L, Martin SL, Sarpong DF. Pharmacy Contributions to Improved Population Health: Expanding the Public Health Roundtable. Prev Chronic Dis. 2020;17:E113. Published 2020 Sep 24. doi:10.5888/pcd17.200350
3. Swarthout M, Bishop MA. Population health management: Review of concepts and definitions. Am J Health Syst Pharm. 2017;74(18):1405-1411. doi:10.2146/ajhp170025
4. Baldoni S, Amenta F, Ricci G. Telepharmacy Services: Present Status and Future Perspectives: A Review. Medicina (Kaunas). 2019;55(7):327. Published 2019 Jul 1. doi:10.3390/medicina55070327