Pinback button for the American Red Cross, 1945. (Photo via Smith Collection/Gado/Getty Images).
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In 1937, the first blood bank in the United States opened at Cook County Hospital in Chicago. In its first year, it facilitated 1,354 blood transfusions — an achievement given that storage was unreliable, donors were recruited only after a crisis, and trust in the system was thin.
Less than a decade later, something had changed. By an order of magnitude.
The American Red Cross had collected 13.3 million pints of blood from 6.7 million donors, operating across 35 fixed centers and 63 mobile units.
Blood transfusion had been transformed from an improvised, heroic act into standard clinical infrastructure.
The Red Cross didn’t invent blood or donors. It solved a coordination problem — standardizing collection, storage, and distribution among many parties until participation became routine rather than heroic.
Community pharmacy in the United States is now confronted with an opportunity – and a challenge – with an uncomfortably similar shape. Pharmacists’ clinical capability exists. The patients are already in the building. The legal permission to deliver and bill for clinical services is expanding rapidly.
What doesn’t exist — what has never fully existed — is the payment and system infrastructure that allows all of those elements to function and grow at scale. That gap is both the defining challenge facing pharmacy today and, as a growing body of research makes clear, the most important opportunity available to close it.
Why This Matters Far Beyond Pharmacy
The stakes of getting this right extend well beyond the pharmacy industry’s economics.
The United States is in the early stages of a worsening physician shortage: the Association of American Medical Colleges projects a deficit of up to 86,000 physicians by 2036, with primary care and underserved geographies bearing the heaviest burden. Meanwhile, healthcare costs continue to rise and patient access continues to deteriorate — wait times lengthen, rural communities lose providers, and patients with chronic conditions receive episodic care at best.
Into that gap steps a resource the system has largely failed to deploy: roughly 330,000 pharmacists, operating out of approximately 54,000 locations, open six days a week, no appointment required, in the neighborhoods where people actually live.
Pharmacists are doctoral-level clinicians with deep expertise in medication management, chronic disease, and preventive care — and they are, by almost any measure, the most accessible healthcare professionals in the country.
The services pharmacists are increasingly authorized to provide — test-and-treat for minor acute illness, chronic disease monitoring and counseling, immunizations, smoking cessation, gaps-in-care closure, medication therapy management, HIV prevention, contraception — are precisely the kind of protocol-driven, lower-acuity interventions that do not require a physician visit but currently either go unaddressed or consume physician time and capacity that could be better spent elsewhere.
That is the policy argument for scaling pharmacist-delivered clinical services.
The Innovation Is Real — and Happening Everywhere
As documented in earlier articles in this series, the economic model of traditional pharmacy dispensing is under severe structural strain. Even as productivity has increased, margins have collapsed. Pharmacies are closing by the hundreds — Rite Aid’s bankruptcy is the most visible casualty.
But a different story has been building in parallel.
Some of the most compelling innovation is coming from regional operators. Thrifty White Pharmacy built a medication synchronization program ensuring patients pick up all chronic medications on a single predictable date each month. That operational convenience is actually a clinical platform: knowing exactly when patients will arrive, Thrifty White delivers adherence coaching, chronic disease monitoring, gap closure, vaccines, and screenings at scale.
Independent pharmacies are equally aggressive. Sam’s Health Mart Pharmacy in rural Missouri, run by forward-thinking Christian Tadrus, participates in a Rural Health Care Services Outreach Program coordinating care and basic health services in communities with few primary care alternatives.
State-level policy has catalyzed real programs as well: North Carolina’s Blue Cross Blue Shield More Than a Script initiative has served more than 10,000 members for diabetes and hypertension management.
The innovation is broad, creative, and real. Yet it is also deeply fragmented. Which raises the question the evidence alone cannot answer: why hasn’t any of this scaled?
The Cold Start Problem — and Why Volume Is Everything
Multiple independent research efforts have now converged on the same diagnosis.
The American Pharmacists Association, in a 2025 report developed through a yearlong learning collaborative of health plan and pharmacy leaders, identified payer-pharmacy collaboration — with standardized credentialing, aligned contracting, and consistent billing — as the essential missing ingredient.
The Alliance for Integrated Medication Management has advanced a regional model it calls Transformation Zones, explicitly designed to build multi-stakeholder coalitions around shared payer compacts for medication management services.
The structural barrier these efforts point to is the same: a network effects “cold start” problem in which there can be great value unlocked if pharmacy clinical services scale, but a challenge in driving enough density of interest on both sides in an area to get started.
Health plan fragmentation is the first barrier. Insurers vary widely in which clinical services they cover, how they credential pharmacists, and which billing codes they accept.
Insufficient patient volume is the second: when a pharmacy can access patients only from a single line of business within a geography, the resulting volume is insufficient to warrant investing further to scale and optimize.
The parallel to how physician practices are shifting to value-based care contracts is instructive: until a ‘tipping point’ of revenue is reached, it is extremely difficult to invest in new processes, technology, and workflows.
The market seems unlikely to reach that inflection point on its own. Without multi-plan engagement across lines of business in a given geography, pharmacies cannot generate sufficient volume. Without sufficient volume and consistent delivery, health plans cannot see outcomes at the scale required to commit further.
Each side waits for the other.
A Framework for Breaking the Deadlock
The solution these converging research efforts point toward is not more pilots.
The APhA’s 2025 recommendations call explicitly for commercial health plans to partner with pharmacists without waiting for legislative mandates, and for credentialing and enrollment processes to be aligned with those of other provider types.
Health plans have the latitude to act, but a challenge as well: a single health plan typically has multiple lines of business, each with their own priorities. Aligning an approach across those lines of business, not to mention across health plans, represents a major coordination challenge.
Increasingly, what is becoming clear is the need for coordination at the regional level to pull health plans and pharmacies together. Leavitt Partners, a health policy firm started by former Health and Human Services Secretary Michael Leavitt, has accordingly announced efforts to form pharmacy stakeholder collaboratives.
Likewise, research funded by the National Council for Prescription Drug Plans Foundation calls for health plan and pharmacy initiatives to scale efforts on a regional basis (disclosure: the author’s consulting firm worked on the research).
Healthcare has solved exactly this kind of coordination problem before. Two decades ago, e-prescribing was frozen: physician adoption stalled because pharmacies weren’t connected, and pharmacies were likewise waiting for physicians.
Surescripts helped break the deadlock by creating a neutral network that aggregated demand and enforced common standards. What helped even more were efforts at the state level – in Michigan, Massachusetts and Rhode Island, among others – to educate both sides, bring them together, and solve real world implementation problems.
Today, e-prescribing accounts for the vast majority of all prescriptions and is mandated in 35 states. The lesson: when no individual actor will absorb coordination risk alone, the answer is infrastructure that makes it rational for multiple actors to move together.
The Financial Case — for Pharmacies and the System
The economic argument for clinical services is not only that they are clinically valuable. At a 2022 Credit Suisse Healthcare Conference, Rite Aid’s CFO noted the company earned roughly $25 in gross profit per flu shot — almost twice the gross profit of a typical prescription.
Clinical services yield higher margins, require less inventory risk, and leverage existing fixed-cost infrastructure. The contrast with dispensing is stark: between 2014 and 2024, while Walgreens saw prescription volume per store rise 30%, gross margin fell from 27.0% to 17.9%.
More dispensing volume. More dispensing revenue. Dramatically less profit.
The system-level upside is equally compelling.
Medication therapy management programs have been shown to save thousands per patient annually, achieving a 12X return on investment. North Carolina’s CheckMeds program saved more than $10 million in a single year. Walgreens’ WellTransitions program was associated with a 46% reduction in unplanned hospital readmissions within 30 days of discharge.
At national scale, these outcomes represent a reduction in healthcare spending potentially in the billions and a meaningful expansion of access in communities that need it most.
What’s Working Against This
The expansion of pharmacist clinical services does not proceed unopposed. The American Medical Association has actively lobbied against scope-of-practice expansion at the state level. Some of that concern is legitimate; some (e.g., citing existing pharmacist workload as a reason to limit their practice scope while simultaneously lobbying against workload burdens that drive physician burnout) appears to reflect guild protection more than patient interest.
The practical effect is a slower, more contested policy environment than the clinical evidence warrants.
The more consequential barrier is federal. The Social Security Act, upon whose statutory authority Medicare rests, does not enumerate pharmacists as providers. As a result, traditional Medicare, the country’s largest payer, cannot reimburse pharmacists for clinical services.
A final challenge? Simple industry inertia.
States are not waiting: every state has enacted some form of pharmacist provider status or scope expansion, with Maryland, North Carolina, Arkansas, and others requiring payers to reimburse clinical services at parity with physicians.
Back to the Beginning
The Red Cross in the 1940’s helped unlock an increase in blood transfusions nearly four orders of magnitude in under a decade.
The science didn’t change dramatically in that interval. The system did: the standardization, the neutral infrastructure, the shared commitment across institutions that made reliable participation possible for everyone.
The Red Cross didn’t solve blood supply by asking every hospital to become a blood bank. It built the coordination layer that allowed hospitals, donors, and logistics to function as a system.
Community pharmacy needs the same thing: not more pilots, not more advocacy, not more evidence — it has decades of all three. It needs coordination infrastructure that makes consistent, scalable, reimbursable clinical services rational for both pharmacies and health plans simultaneously.
The physician shortage is real and worsening. The access gap is real and widening. The solution — trained, trusted, accessible clinicians already present in nearly every community in the country — is sitting largely idle, waiting for a business model that makes it rational to act.
The roadmap is clear. The window is open. The only thing that has ever been missing is the structure. It’s time to build it.