How Population Health Pharmacists Improve Adherence
- aPHP
- Feb 13
- 13 min read
Updated: 4 days ago
Summary: This blog post focuses on Medicaid population health pharmacists, highlighting how they apply strategic interventions to improve medication adherence, support value-based prescribing, and strengthen outcomes using targeted population health pharmacy strategies.
Why Pharmacists Are Essential to Population Health Strategies
Population health is a proactive, patient-centered approach that improves outcomes across entire communities. It addresses systemic barriers, strengthens chronic disease management, and reduces disparities through coordinated, data-driven care. This model relies on data-driven decision making and the contributions of interdisciplinary population health management teams to identify care gaps, prioritize resources, and advance health equity.
Within this evolving landscape, the roles of pharmacists in population health are expanding, especially in managed care environments. Many of their interventions are designed to support high-risk populations, including racial and ethnic minorities with limited access to care, individuals with weakened immune systems, older adults, and those facing high rates of chronic disease or premature mortality.
This blog post focuses on Medicaid population health pharmacists, highlighting how they apply strategic interventions to improve medication adherence, support value-based prescribing, and strengthen outcomes using targeted population health pharmacy strategies. Their work contributes to broader population health initiatives. It reinforces the success of value-based care models and incentives that aim to improve access, equity, and long-term population health outcomes.
What Is Population Health Pharmacy?
Population health pharmacy is a care delivery model that integrates clinical expertise, public health principles, and real-world data to transform health outcomes at scale.
Practiced across Medicaid and commercial health plans, this approach positions pharmacists to lead population health pharmacy programs that reduce disparities, support incentivized value-based care (VBC) contracts programs, and improve system performance.
These programs are often rooted in telepharmacy population health services and pharmacist-led chronic disease management, two core elements of the clinical expertise model. Together, they enable pharmacists to deliver proactive care, particularly for high-risk populations with limited access to pharmacy services through traditional in-person channels.
Systematic evidence demonstrates that pharmacist-led interventions for chronic diseases, such as diabetes, hypertension, and hyperlipidemia, improve outcomes, supporting the scalability of this model in both rural and primary care settings.⁴
At the Academy of Population Health Pharmacy (aPHP), we define population health pharmacy by its ability to operationalize VBC through scalable, pharmacist-led population health initiatives grounded in data-driven decision making.
Core focus areas of population health pharmacy programs include:
Improving medication adherence
Increasing access to essential medications
Bridging care gaps to advance health equity
Preventing adverse drug reactions through safe, evidence-based prescribing
Reducing the total cost of care while supporting long-term outcomes
As population health pharmacy leaders, pharmacists play a vital role in aligning public health goals with clinical performance across managed care, accountable care organizations (ACOs), and interdisciplinary care settings.
What Is the Main Goal of Population Health?
Advance equity and outcomes
Treat individual patient illness
Expand service volume
Reduce prescription costs
Poll #2: Did You Choose Correctly? The answer is revealed at the end of this blog. Scroll down to see how your choice compares with the core aim of population health.
What Is a Medicaid Population Health Pharmacist?
A population health pharmacist is a system-focused clinician who applies data insight, equity principles, and interdisciplinary strategy to strengthen care delivery across defined populations. Instead of operating in siloed roles, they work within healthcare systems to close gaps, support coordinated care, and align clinical interventions with population health pharmacy goals.
A Medicaid population health pharmacist specializes in improving outcomes for high-risk populations served by public health programs. In these settings, they lead pharmacist-led initiatives that expand access, improve medication adherence, influence quality metrics, and shape policies that drive whole-person, population-level impact.
Pharmacy’s Role in VBC: Strategies for Measurable Impact
Value-based care (VBC) is a healthcare model that ties provider reimbursement to patient outcomes rather than service volume. It prioritizes quality metrics, such as medication adherence, chronic disease control, and patient experience, ensuring that care is both cost-effective and clinically meaningful. VBC aligns closely with the Triple Aim framework, which seeks to enhance patient experience, improve population health, and reduce per capita healthcare costs.
Because VBC aims to improve long-term outcomes, reduce costs, and promote value-based care standardization, population health strategies are foundational to its success. These strategies shift the focus from isolated encounters to coordinated, preventive interventions across entire populations.
Medicaid population health pharmacists play a central role in this shift. Positioned at the intersection of managed care, public health, and clinical pharmacy, they lead targeted, pharmacist-led interventions that:
Address chronic disease burdens and reduce disparities in high-risk populations
Improve medication adherence as a value-based care quality measure
Apply real-world data to inform clinical decisions and population-level outreach
Guide formulary decisions using value-based prescribing principles
Lower avoidable utilization through medication therapy management (MTM) and other pharmacist-led services
In many systems, pharmacists also contribute to incentivized value-based care contracts, which reward health plans and providers for achieving specific benchmarks, such as improved adherence rates, reduced hospitalizations, and more effective care coordination. These contracts link pharmacy performance directly to outcomes and payment, positioning pharmacists as essential contributors to team-based care delivery.
By combining data-driven decision making with clinical expertise, pharmacists drive measurable performance in VBC while advancing health equity and population health goals.
How Pharmacist-Led Population Health Is Reshaping Provider Recognition
Historically, pharmacists, once known as druggists and chemists, played a direct role in patient care, chronic disease management, and therapeutic decision-making. However, the 1951 Durham-Humphrey Amendment (Fig. 1) redefined this relationship by transferring prescriptive authority and primary patient care responsibilities to physicians, effectively relegating pharmacists to dispensing roles within physician-led models.
Today, that legacy is shifting. Medicaid and managed care pharmacists are reclaiming their place in the healthcare delivery system through pharmacist-led population health strategies that emphasize access, adherence, and policy-informed care. These strategies enhance health outcomes and reinforce the pharmacist’s role as a clinical provider, delivering a measurable impact at both the individual and population levels.
This evolution supports the broader national movement toward pharmacist provider status, as pharmacists prove their value in care coordination, health equity, and data-informed decision-making. By bridging the gap between community health needs and system-level accountability, population health pharmacy is helping restore the pharmacist’s identity as a care provider and leader in outcome-based care.
Figure 1. Summarizes the impact of the Durham-Humphrey Amendment, highlighting pharmacy’s shift from autonomous prescribing to a restricted dispensing role, its effects on patient care, and ongoing reforms aimed at restoring pharmacist prescribing power.
Real-World Population Health Pharmacy in Action: The Work of Dr. La Kesha Y. Farmer
Dr. La Kesha Y. Farmer, founder of aPHP, exemplifies how population health pharmacy translates into measurable value. While serving as a population health clinical pharmacist within a Managed Care Organization (MCO), she led multiple Medicaid population health pharmacy outreach programs focused on closing care gaps and advancing health equity.
Her initiatives:
Advanced adherence among high-risk populations
Closed treatment gaps through pharmacist-led outreach
Contributed to measurable cost savings for the health plan
These results underscore the effectiveness of outcome-based pharmacy programs in Medicaid when aligned with value-based care goals. Studies further validate this impact, showing that Medicaid pharmacists improve adherence, reduce disparities, and elevate performance in managed care settings.⁶
Improving Medication Adherence in Medicaid: HEDIS, Advocacy, and Impact
Medicaid population health pharmacists go beyond traditional MTM, leveraging policy-driven interventions and Medicaid-specific adherence strategies to drive measurable improvements in medication adherence. Their work focuses on:
HEDIS Measures: Leveraging Data for Optimal Outcomes
Enhancing Patient Access and Experience
Empowering Patients Through Tailored Education
Leveraging Technology to Improve Adherence
Optimizing MTM for Medicaid Populations
Addressing Social Determinants of Health (SDOH)
Each section below will explore how Medicaid population health pharmacists drive measurable impact in these areas to improve medication adherence and patient outcomes.
HEDIS Measures: Leveraging Data for Optimal Outcomes
As part of population health pharmacy initiatives, Medicaid pharmacists play a crucial role in enhancing medication adherence by utilizing claims data and metrics to identify and support non-adherent members, ultimately driving measurable outcomes.
An example of metrics includes the Healthcare Effectiveness Data and Information Set (HEDIS), a set of quality measures established by the National Committee of Quality Assurance (NCQA).
Real-world programs, such as the Targeted Intervention Program (TIPs), demonstrate how HEDIS-driven pharmacist interventions improve clinical performance.⁹
These programs support Medicaid beneficiaries in meeting national health objectives while also providing valuable prescribing insights, such as drug utilization reviews (DURs), to optimize medication use and improve patient safety.
Enhancing Patient Access and Experience
Medicaid population health pharmacists enhance patient experience by ensuring beneficiaries receive optimized, cost-effective care.¹ This includes identifying barriers, triaging patient-provider concerns, and facilitating connections to preferred providers.
These efforts align with the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, which prioritizes patient-centered care and experience-driven provider selection, both key factors in Medicaid quality initiatives.
Empowering Patients Through Tailored Education
Medicaid population health pharmacists deliver personalized education that reinforces how medication adherence directly impacts the management of chronic conditions, such as diabetes, hypertension, and asthma, helping patients achieve improved health outcomes.
The typical adherence benchmark for most chronic medications is 80%, while medications for HIV require sustained adherence rates closer to 90% to maintain treatment effectiveness and viral suppression.
By building trust and employing motivational interviewing techniques, including reflective listening, patient-centered goal setting, and addressing ambivalence, pharmacists facilitate meaningful conversations that promote behavior change.
Through culturally competent communication, they empower individuals to take control of their care and see adherence as a path to long-term stability. This whole-person approach reflects the World Health Organization’s definition of health as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.”
Recent research highlights the critical role of pharmacist-led deprescribing in improving medication safety for patients with chronic diseases.
A pharmacist-led intervention study found that patients receiving pharmacist-driven deprescribing support had a median of one medication deprescribed, while the control group experienced an average increase of 0.44 medications.²
Notably, patients in the intervention group with heart failure showed significant improvements in ejection fraction.²
Pharmacists already implement simple yet effective tools, such as medication guides, consultations, and targeted interventions, to improve patient understanding and medication adherence.
Their role in deprescribing and education is undeniable; yet, studies like this underscore the necessity of pharmacist-inclusive practices over exclusion, a pattern that has been repeatedly observed, most recently in the GeriPal super studies and many others before it.
Leveraging Technology to Improve Adherence
Medicaid population health pharmacists integrate digital health tools into patient care, harnessing technology as a vital strategy for improving medication adherence.
These innovations enhance patient engagement, streamline provider communication, and address barriers to adherence.
Key examples include:
Adherence Reminder Apps: Assist patients in staying on track with their medication schedules.⁷
Telehealth Services: Facilitate real-time, remote consultations to identify and resolve adherence challenges efficiently.⁷
Mobile health (mHealth) tools, including devices such as smartphones, blood pressure monitors, and wireless scales, provide timely reminders and enhance patient-provider communication.⁷
By leveraging these digital solutions, Medicaid population health pharmacists promote sustained medication adherence, resulting in improved health outcomes for Medicaid populations.
Optimizing MTM for Medicaid Populations
Medicaid population health pharmacists apply managed care principles and formulary management strategies to enhance medication adherence, mitigate prior authorization barriers, and reduce overall healthcare costs.
They support adherence through tools like special packaging, synchronized refills, and patient-centered coordination.
Beyond adherence, MTM serves as a bridge to care by addressing patient-specific barriers and integrating pharmacy services into broader healthcare initiatives.
Addressing Social Determinants of Health (SDOH)
Medicaid population health pharmacists play a critical role in addressing barriers to care, such as SDOH, by helping MCOs bridge care gaps and reduce disparities that contribute to poor medication adherence.¹
They serve as integral members of the healthcare team, collaborating with diverse stakeholders to address SDOH-related challenges that affect medication access and adherence, ensuring more equitable healthcare access and improved health outcomes.
Through evidence-based strategies, such as Medicaid Adherence Telepharmacy Programs, Medicaid population health pharmacists also strengthen treatment outcomes and support broader public health goals.
6 Key SDOH Initiatives Where Medicaid Pharmacists Play a Vital Role:
Care Coordination.
MCOs have integrated community health workers (CHWs) into health plans, enabling Medicaid pharmacists within these organizations to train CHWs as pharmacy liaisons, supporting medication adherence, retention, and continuity of pharmaceutical care.
Food and Transportation Support.
Collaborating with community-based organizations (CBOs) to offer transportation assistance and connect patients with Food Rx programs,¹ such as Produce Prescriptions Programs (PRx), which address food insecurity while promoting dietary habits that support chronic disease management goals.
Whole-Person Care Programs.
Facilitating whole-person care using programs like California’s Advancing and Innovating Medi-Cal (CalAIM) to improve care support and address broader health needs.
Medication Access.
Activating prescription delivery services removes access barriers, ensuring patients receive medications without mobility or transportation challenges.¹
Closed-Loop Referrals.
Utilizing platforms like 211 or FindHelp.org to facilitate closed-loop referrals, ensuring patients are successfully connected to essential social services and that healthcare providers receive confirmation of completed referrals, and removing barriers that interfere with medication adherence.
Workforce Training.
Research supports the use of SDOH-focused training for pharmacy interns and technicians to assess social needs and identify adherence barriers.³ Medicaid population health pharmacists, including Dr. Farmer, have implemented similar strategies in managed care, reinforcing the impact of pharmacist-led SDOH initiatives in population health pharmacy.
The Role of Medicaid Population Health Pharmacists in Health Equity and Policy
Medicaid population health pharmacists function as Medicaid Champions, leading policy initiatives by analyzing adherence trends and presenting actionable recommendations to Medicaid policymakers and program leaders.
Their advocacy addresses systemic barriers, such as formulary restrictions, copay challenges, and access limitations, ensuring access to care remains a priority while improving medication adherence.⁸
By shaping policies that eliminate disparities, their leadership advances equitable care and drives systemic change.
Dr. Farmer exemplified this impact by presenting her clinical pharmacy best practices on improving medication adherence to the Global Medi-Cal DUR Board of the California Department of Health Care Services (DHCS).
She shared how she integrated culturally competent care models into her telepharmacy outreach program development to advance health equity, driving improved health outcomes.
Her expertise in cultural competency is further detailed in 9 Proven Strategies for Reducing Health Disparities in Pharmacy Practice, which highlights actionable approaches to addressing health inequities and fostering systemic change.
Medicaid Population Health Leaders: Redefining Pharmacy’s Role in VBC
The impact of Medicaid population health pharmacists is evident in their leadership of initiatives that improve medication adherence, advance equity, and optimize healthcare resources. The following strategies demonstrate how these pharmacists strengthen patient outcomes, reduce system inefficiencies, and redefine what leadership in pharmacy practice looks like today.
Medicaid Population Health Pharmacists Reduce Healthcare Costs by Improving Medication Adherence
Population health pharmacists working within Medicaid programs help decrease hospitalizations and emergency room visits, generating substantial cost savings.¹ ⁵
Given that the U.S. has the highest per capita GDP for healthcare, these pharmacists, like their counterparts in non-Medicaid settings, help bridge cost gaps by optimizing medication use and reducing preventable health expenditures.
This finding aligns with the Triple Aim framework, which aims to enhance patient experience, improve population health, and lower healthcare costs, thereby reinforcing the population health pharmacist’s role in delivering sustainable, high-quality care.
Medicaid Population Health Pharmacists Advance Cultural Competency in Pharmacy Practice
Cultural competency is a cornerstone of population health pharmacy, ensuring that medication adherence strategies account for diverse patient needs, beliefs, and social determinants of health.
Medicaid population health pharmacists integrate culturally tailored interventions into patient care, recognizing how language barriers, historical mistrust, and systemic inequities influence adherence.
Race concordance, defined as patients being treated by healthcare providers of the same racial or ethnic background, has been shown to increase trust and engagement, reinforcing the need for diverse representation within pharmacy leadership.
By embedding cultural competency into Medicaid pharmacy programs, population health pharmacists strengthen patient relationships, improve adherence, and advance health equity.
Medicaid Population Health Pharmacists Collaborate with Interdisciplinary Care Teams to Improve Medication Adherence
Medication adherence requires more than pharmacy expertise; it depends on a multidisciplinary, team-based approach to drive sustainable outcomes.
Medicaid population health pharmacists collaborate with physicians, case managers, and care coordinators to align medication plans with broader treatment goals.
By partnering with medical directors and clinical teams, they improve medication access, optimize therapeutic outcomes, and reduce health disparities.
Their leadership in clinical strategy ensures that adherence remains a shared priority across healthcare touchpoints.
How Medicaid Population Health Pharmacy Reduces Costs and Improves Outcomes
Medicaid population health pharmacists transform Medicaid population health pharmacy principles into reproducible outcomes, reducing costs and improving medication adherence.
The following case study highlights pharmacist-led interventions that successfully improved adherence and strengthened Medicaid program efficiency.
A Medicaid initiative targeting high-risk, non-adherent patients with chronic conditions integrated MTM sessions and community-based partnerships (CBOs), resulting in:
A 15% increase in adherence rates among participants.¹
A 25% reduction in hospital readmissions through improved chronic disease management.¹
Significant cost savings, reinforcing the effectiveness of pharmacist-led interventions.¹
These results underscore the critical role of Medicaid pharmacists in improving medication adherence and advancing sustainable population health pharmacy outcomes.
Medication Adherence and Population Health: Strengthening Outcomes in VBC
Medicaid population health pharmacists are more than medication experts; they are population health champions, driving value-based care and shaping the future of healthcare.
This article has demonstrated how Medicaid pharmacists close care gaps, optimize healthcare frameworks, and restore pharmacy’s role in direct patient care.
Their leadership in population health and value-based care marks a shift from the limitations imposed by the 1951 Durham-Humphreys Amendment, reaffirming pharmacists as key healthcare providers.
As pharmacist-driven programs continue to grow, Medicaid pharmacists remain at the forefront of innovation, integrating policy-driven interventions, data-informed strategies, and clinical expertise to transform healthcare delivery and improve patient outcomes.
Their impact underscores the necessity of expanding pharmacist-led initiatives, particularly within state-based population health models (looking at you, DHCS).
Sustaining their role requires ongoing investment, system-wide support, and collaboration to ensure pharmacist-driven solutions remain at the forefront of equitable and sustainable healthcare.
Answer to poll #1: all of the above.
References
Centers for Disease Control and Prevention. “Medication Therapy Management in Medicaid.” Centers for Disease Control and Prevention website. Updated March 2021. Accessed December 26, 2024. https://www.cdc.gov/cardiovascular-resources/media/MTM_in_Medicaid-508.pdf.
Chan, Mabel, et al. "Pharmacist-Led Deprescribing for Patients With Polypharmacy and Chronic Disease States: A Retrospective Cohort Study." J Pharm Pract. 2023 Oct; 36(5):1192-1200. Accessed February 13, 2025. https://pubmed.ncbi.nlm.nih.gov/35522029/.
Daly, Christopher J., and David M. Jacobs. “Implementing a Social Determinants of Health Program.” University at Buffalo School of Pharmacy and Pharmaceutical Sciences, n.d., Community Pharmacy Foundation. Accessed 31 Jan. 2025.
Greer N, Bolduc J, Geurkink E, et al. Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared to Usual Care [Internet]. Washington (DC): Department of Veterans Affairs (US); 2015 Oct. INTRODUCTION. Available from: https://www.ncbi.nlm.nih.gov/books/NBK362935/
Moczygemba, Leticia R, et al. “Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs.” Am J Manag Care, vol. 25, no. 11, 14 Nov. 2019, www.ajmc.com/view/comprehensive-health-management-pharmacistdelivered-model-impact-on-healthcare-utilization-and-costs?utm_source=chatgpt.com. Accessed 31 Jan. 2025.
Montgomery, E., Sherod-Harris, T., Adkins, M., & Hinely, M. “Impact of Pharmacy Involvement on Care Gap Closure in Managed Medicaid Patients.” Am J of Health-System Pharmacy, Published 21 Nov. 2024, doi:10.1093/ajhp/zxae328. Accessed January 30, 2024. https://pubmed.ncbi.nlm.nih.gov/39570898/.
The American Journal of Managed Care. “Cost Savings From an mHealth Tool for Improving Medication Adherence.” Am J Manag Care. Published September 1, 2023. Accessed December 26, 2024. https://www.ajmc.com/view/cost-savings-from-an-mhealth-tool-for-improving-medication-adherence.
The American Journal of Managed Care. “Reducing Barriers to Medication Access and Adherence for ACA and Medicaid Participants: A Peer-to-Peer Community-Based Approach.” Am J Manag Care. Published April 22, 2022. Accessed December 26, 2024. https://www.ajmc.com/view/reducing-barriers-to-medication-access-and-adherence-for-aca-and-medicaid-participants-a-peer-to-peer-community-based-approach.
Weiser P. “How Pharmacists Can Influence HEDIS Measures and Value-Based Care.” Outcomes™ Blog. September 21, 2022. Accessed December 29, 2024. https://blog.getoutcomes.com/perspectives/how-pharmacists-can-influence-hedis-measures-and-value-based-care.
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