Cone Health

Cone Health
Greensboro, NC

As the Centers for Medicare & Medicaid Services moves toward enrolling all Medicare beneficiaries in value-based care (VBC) arrangements,¹ pharmacists are well positioned to improve quality measures and reduce unnecessary utilization,^2-4 yet little guidance exists on how to scale these services across an entire network. This program combined previously separate embedded and population health pharmacy teams into one payor-agnostic primary care pharmacy model in which each pharmacist is accountable for both disease state management and quality gap closure.

Building on a prior pharmacist-led health equity initiative for hypertension control,⁵ in 2024 the health system merged its medical group and clinically integrated network (CIN) pharmacy teams. These teams had operated with separate funding, workflows, and reporting, which led to provider and patient confusion and overlapping care. Each primary care clinic was assigned one pharmacist responsible for provider referrals and for proactive, population-level quality work. Most pharmacists hold Clinical Pharmacist Practitioner licensure. They conduct a hybrid of in-person and virtual visits and follow standardized diabetes and hypertension care pathways. Each pharmacist also spends four to eight hours weekly on outreach driven by payor reports, including working with pharmacy technicians to review medication adherence metric gaps prioritized by last impact date. Patients with medication access barriers are screened for coverage and patient assistance programs. A discrete documentation flowsheet in the electronic medical record captures the category of care, drug therapy problems, and interventions, and feeds a productivity dashboard. Cross-training and the use of pharmacy learners supported the expansion, as did close partnership with medical group and CIN leadership, who jointly funded positions. Together these allowed the program to grow from six clinics to more than 80 employed and independent practices.

In 2025, 19 pharmacists, one pharmacy technician, and two pharmacy residents engaged 11,363 patients across 35,495 encounters and completed 108,346 clinical interventions. Patients in the diabetes program had a mean hemoglobin A1C reduction of 1.5% (from 9.2% to 7.7%). The percent meeting the glycemic control measure (A1C <9%) rose from 54% to 78%. Patients in the hypertension program had a mean blood pressure reduction of 10/4 mmHg. The share meeting the control measure (<140/90 mmHg) rose from 41% to 75%. Pharmacists addressed 9,908 medication adherence gaps over 13,403 engagements, achieving 84% gap closure. All contracted adherence measures across three full-risk Medicare Advantage contracts reached 4 stars. Diabetes-related emergency department visits and hospitalizations decreased by 35.5% (rate ratio 0.645; 95% CI 0.418–0.996; p=0.048). A health economist analysis found a $76 per-member-per-month cost reduction compared with a matched cohort. Manufacturer assistance enrollment generated an estimated $27 million in savings for patients and payors. The share of primary care prescriptions filled at the health system's integrated community pharmacies rose from 26.9% to 31.9%.

Combining embedded disease management and population health work into a single pharmacist role is a scalable, resource-efficient way to improve clinical, quality, and financial outcomes in value-based care across both employed and independent primary care practices, in alignment with ASHP's Practice Advancement Initiative 2030.⁶

References

1. Centers for Medicare & Medicaid Services. Innovation Center strategy refresh. CMS.gov. Published 2021. Accessed July 15, 2026. https://www.cms.gov/priorities/innovation/strategic-direction-whitepaper
2. Patti M, Colmenares EW, Abrahamson A, Weddle S, Cavanaugh J, Deyo Z, Vest MH. Impact of pharmacist participation in the patient care team on value-based health measures. Am J Health Syst Pharm. 2022;79(19):1645-1651.
3. Rinehart SN, Collins C, Glover J, Rice WM. Evaluation of a pharmacist-driven medication adherence enhancement service. J Manag Care Spec Pharm. 2021;27(4):507-515.
4. Chung N, Rascati K, Lopez D, Jokerst J, Garza A. Impact of a clinical pharmacy program on changes in hemoglobin A1C, diabetes-related hospitalizations, and diabetes-related emergency department visits for patients with diabetes in an underserved population. J Manag Care Spec Pharm. 2014;20(9):914-919.
5. Harper CT, Hammer SK, Jegede OE, Davidson SC, Kern L, Randolph T, Tobb K. Improving health equity in hypertension control for Black patients. Jt Comm J Qual Patient Saf. 2026;000:1-8.
6. American Society of Health-System Pharmacists. PAI recommendations. ASHP. Accessed July 28, 2026. https://www.ashp.org/pharmacy-practice/pai/pai-recommendations

Left to Right: Tiffany Benfield, Julie Pruitt, Bethany Bonner, Allyson Marsh, Raven Griffin, Cristy Patille, Luke Van Ausdall, Tyler Swann, Eileen Shepperson, Ali Lynch, Catie Harper, Pete Koval, Toni Mack, Stacey Hammer, Jill Simcox, Elisabeth Delles, Layna Fox, Katina Jones, Michael Maize, Jacob Potts

Not pictured: Katrina Bitcon, Tammy Eckard, Cheryl Gentry, Angela Herring, Avery Schmidt, Michelle Tran, Lindsay Zink