Sustainability
Loren Bonner
Under the right circumstances and in a favorable regulatory environment, pharmacist-led primary care services are financially sustainable, according to real-world evidence from Idaho published November 1, 2025, in JAPhA.
“When you look at real reimbursement and realistic visit volumes, it becomes clear that pharmacists can function much like other midlevel providers in primary care, particularly for chronic disease management in collaboration with physicians,” said Jordin Millward, PharmD, lead study author and clinical assistant professor from Idaho State University College of Pharmacy.
Idaho’s regulatory environment has created an opportunity to actually test whether pharmacist-led primary care services can be financially sustainable when billed like other nonphysician providers. In Idaho, pharmacists practice under a standard of care model, which allows them to prescribe medications, order labs, and manage chronic disease states without a CPA. Pharmacists can also bill Idaho Medicaid.
In her own primary care practice, Millward works collaboratively with physicians but also sees patients independently for chronic disease management and bills evaluation and management (E/M) codes under her own national provider identifier (NPI).
“We do not have payment parity laws for commercial payers, but we at the Idaho State University L.S. Skaggs College of Pharmacy had developed relationships with some of the major ones like Blue Cross of Idaho and Blue Shield of Idaho, and they had agreed to pilot payment for pharmacist evaluation and management services,” she said.
Breaking even
Extracting descriptive reimbursement data from the EHR and calculating average reimbursement rates per visit, Millward and a fellow researcher found that $123.25 was the average reimbursement for pharmacists per patient visit.
More specifically, the break-even threshold (one FTE, no support staff, 30% benefits) was six patients per 8-hour clinic day. At one FTE with support staff, sustainability required eight patients per clinic day, they found.
“What stood out to me most was how few patients needed to be seen each day to break even financially,” Millward said. “Once we looked at the actual reimbursement data, it became clear that sustainability was possible at a much lower visit volume than many people expect.”
To target an additional profit of $100,000 per year for one FTE pharmacist with support staff, the threshold was 12 patients per clinic day.
Millward said these estimates are conservative, too, as they were likely undercoding visits early on.
“When everything came together, it started to feel fairly straightforward that pharmacists can integrate successfully into primary care if a few things are in place: relationships with commercial payers, a workable approach to Medicare billing, and a steady stream of patient referrals that allow pharmacists to see patients independently rather than only through co-visits,” she said.
Some outreach was required to navigate commercial payer contracts, but Millward said she was also struck by how easy it was to contract with these payers just by adding her pharmacist NPI to existing provider contracts through established clinic credentialing workflows.
“One of the most surprising findings was how often commercial payers reimbursed pharmacist visits at the same rates they pay other providers for the same E/M codes,” Millward said. “There’s a common assumption that pharmacists will automatically be paid less, even when they’re credentialed and billing independently, and that wasn’t what we saw in this dataset.”
While the reimbursement was lower for chronic care management visits than E/M visits paid by Medicare, Millward said it was still meaningfully higher than what they would have generated through incident-to billing codes.
“Ultimately, this study reinforces that the only way to know whether a model will work in a given setting is to start contracting with payers and submitting claims,” she said.
“I’d encourage pharmacists and clinic leaders not to underestimate the importance of contracting directly with payers and opening a dialogue with them,” said Millward. “Even in Idaho, where we don’t have provider parity laws, we made a deliberate effort to build relationships with third-party payers, and that work is starting to pay off.”
In states like Idaho, under the right circumstances, this work could even support the possibility of pharmacist-run practices.
Beyond Idaho
One of the strengths of the study is that it used real-world reimbursement data rather than projections.
Millward said the model may be especially helpful for smaller or independent practices that can’t rely entirely on value-based care infrastructure to fund pharmacist services.
“But our outcomes data is also a reminder that pharmacists don’t just ‘add visits’—we improve care, which can increase our value to health care systems as well,” she said.
While Idaho offers a favorable regulatory environment, this approach is not limited to Idaho, Millward noted.
“In most states, pharmacists are not explicitly prohibited from contracting with third-party commercial payers, even if Medicaid billing is not allowed,” she said. “That means clinics can still make real progress toward sustainability through commercial credentialing and E/M billing.” ■
Standard of care defined
The standard of care framework removes the regulatory burden on states to write detailed rules on how to implement and enforce legislation for pharmacy practice. It eliminates the need to continually go to the legislature and ask for more clinical services to be added to the approved list.
In this model, which is in place in Idaho and a few other states, the practitioner can practice to the top of their ability.
Physicians, nurses, and all other health care providers are regulated with a standard of care model. ■