Enhancing primary care: The impact of pharmacist-led chronic care and AI-driven telehealth

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Chronic diseases are a leading driver of health care costs, accounting for 90% of the nation’s $4.5 trillion in annual health care expenditures. For primary care physicians (PCPs), medication therapy problems (MTPs) — including nonadherence, adverse drug interactions and inappropriate prescribing — pose significant challenges in managing high-risk populations.

As value-based care models reshape primary care reimbursement, integrating artificial intelligence (AI)-driven virtual clinical pharmacist-led medication management offers a scalable, cost-effective solution to improve patient outcomes and financial sustainability.

Cynthia Chioma Nwaubani, PharmD, BCGP
© PharmD Live

With the introduction of Advanced Primary Care Management (APCM) services and the continued evolution of Primary Care First (PCF), PCPs have an opportunity to optimize participation in these Centers for Medicare & Medicaid Services (CMS) models. By incorporating chronic care management (CCM), remote patient monitoring (RPM), medication therapy management (MTM) and remote therapeutic monitoring (RTM) alongside pharmacist interventions, primary care practices can enhance patient outcomes, financial performance and operational efficiency.

The role of pharmacist-led interventions in primary care

MTPs contribute to avoidable hospitalizations, adverse drug events (ADEs) and rising health care costs. Common issues include medication reconciliation discrepancies, nonadherence, inappropriate prescribing and harmful drug-drug or drug-disease interactions. Left unaddressed, these problems compromise patient safety, increase health care utilization and add to the burden on PCPs.

Pharmacists play a critical role in mitigating these risks by conducting comprehensive medication reviews, providing ongoing MTM, deprescribing when necessary, and educating patients on adherence and chronic disease management. Their expertise in optimizing medication regimens ensures safer, more effective treatment plans and better patient outcomes.

The impact of pharmacist interventions is evident in a recent six-month study at a multiclinic nephrology practice, where pharmacists resolved 2,875 MTPs, leading to $8.6 million in preventable health care costs saved. These interventions also reduced hospitalizations and emergency room visits while improving medication adherence and patient engagement. By embedding pharmacists within primary care workflows, practices can proactively address medication-related complications, enhance chronic disease management and improve overall patient outcomes.

Aligning pharmacist-led interventions with CMS value-based care models

As CMS continues to prioritize value-based care, pharmacist-led interventions and AI-driven telehealth align seamlessly with key primary care models, including APCM and PCF. These models emphasize care coordination, chronic disease management and patient engagement — areas where pharmacists play a vital role in improving outcomes and reducing costs.

The APCM model focuses on enhanced care coordination and chronic disease management, making pharmacist interventions highly valuable. Pharmacists contribute by reducing hospitalizations and provider workload burden and burnout through proactive medication management, improving adherence monitoring via remote check-ins, and educating patients on medication use and chronic disease self-management.

The PCF model, which seeks to lower hospital utilization and improve quality metrics, benefits from pharmacist-led interventions and AI-powered telehealth solutions. RPM and RTM provide real-time tracking of high-risk patients, while pharmacist-driven medication optimization and adherence support help prevent costly complications. Improved care coordination among PCPs, pharmacists and specialists further enhances continuity of care.

AI-driven telehealth: A game-changer in chronic disease management

While pharmacist interventions are essential for medication management, AI-powered telehealth solutions take chronic care to the next level by providing real-time insights and proactive intervention capabilities. AI-driven analytics predict medication adherence risks, helping providers identify patients at risk of missing doses or experiencing complications.

RPM and RTM enhance patient oversight by enabling continuous tracking of medication use, allowing for early detection of nonadherence or adverse reactions. Additionally, AI-powered decision-support tools assist physicians and pharmacists in identifying and preventing adverse drug events, reducing the likelihood of hospitalizations.

AI-driven RTM allows PCPs to track adherence patterns, detect missed doses and intervene early, preventing disease exacerbations and costly hospital readmissions. By integrating AI-driven telehealth with pharmacist-led interventions, primary care practices can establish a more responsive, data-driven approach to chronic disease management, improving both patient outcomes and health care efficiency.

Financial and clinical benefits for primary care physicians

Integrating pharmacist-led MTM, CCM, RPM and RTM services presents significant financial and clinical advantages for primary care physicians. These services are Medicare-billable, offering new revenue streams under CMS reimbursement models while incentivizing proactive CCM. By leveraging these interventions, practices enhance financial sustainability while improving patient care.

Beyond revenue optimization, pharmacist involvement directly improves quality measures, leading to higher reimbursement rates and shared savings under APCM and PCF. By addressing medication adherence, optimizing therapy regimens and preventing ADEs, these interventions help maximize performance-based incentives while delivering better patient outcomes.

Additionally, delegating medication management to pharmacists reduces the administrative burden on PCPs, allowing them to focus on diagnostics, patient engagement and treatment planning. AI-driven decision-support tools further streamline workflows by automating medication reconciliation and adherence monitoring, minimizing manual tasks. This reduces physician burnout while ensuring that medication-related complications are proactively managed.

Shaping the future of primary care

As CMS prioritizes team-based, high-value care, integrating pharmacist interventions and AI-driven telehealth is essential for primary care practices seeking to enhance patient outcomes, reduce costs and optimize financial performance. By leveraging these strategies, PCPs can improve medication management, prevent avoidable hospitalizations through real-time adherence tracking, and maximize reimbursement opportunities under APCM and PCF.

Embracing pharmacist collaboration and AI-powered chronic care solutions enables practices to lead the transformation toward proactive, cost-effective and high-quality health care. By adopting medication management innovations, PCPs can improve chronic disease care, enhance financial sustainability and align with evolving CMS value-based care models, ensuring better patient outcomes and long-term practice success.

Cynthia Chioma Nwaubani, PharmD, BCGP, is founder and CEO of PharmD Live, driving its growth strategies and organizational goals, with a focus on expanding innovative clinical pharmacy solutions across U.S. health care verticals. As an entrepreneurial and analytical leader, she excels in problem-solving, streamlining operations and optimizing productivity to deliver cost-effective, patient-centered outcomes.