Aligning ‘pay-for-outcomes’ pharmacy model with reimbursement
LAS VEGAS — As the healthcare industry moves toward adopting outcomes-based reimbursement, independent pharmacy owners are faced with a stark reality — they need to invest in the ability to deliver clinical outcomes long before that ability is adequately reimbursed by an evolving payment model.
Good Neighbor Pharmacy, however, is looking to ease that burden.
The question on how to successfully transition from the fee-for-service payment model in place today to the pay-for-outcomes model of the future is “one of the most complicated questions that the industry has been wrestling with for years,” noted Dave Neu, EVP Retail Strategy at AmerisourceBergen and President of Good Neighbor Pharmacy. “It’s interesting that before medication therapy management, we had reimbursement for cognitive services. We had in there a bit of clinical consulting, and it has always been about who’s going to pay for it?” he said. “And the other piece — without a centralized patient record, what value is there?”
That’s all starting to change now, slowly but surely, Neu said. “One of the things that’s happened recently with the change in health care and the Star measures, is that there is now a difference in technology to capture this information,” he said. “It’s not perfect, but the payers and the PBMs have gotten smart, and they have put incentives and disincentives in place,” he said. If you don’t show specific changes or outcomes, the reimbursement for that work may be cut or, even worse, eliminated altogether.
The recent J.D. Power’s 2015 U.S. Pharmacy Study, which ranked AmerisourceBergen’s Good Neighbor Pharmacy network the highest in customer satisfaction among chain drug stores, also found that a pharmacist’s individual attention can have an impact on loyalty, as 44% of customers who talk to their pharmacists strongly agree that they feel loyal to a pharmacy, compared with 35% of people who don’t talk to a pharmacist. The findings emphasize the importance of pharmacist’s involvement beyond a fee-for-service model.
Eventually there will be a balance, a kind of payment for services and reimbursement for outcomes management that will morph over time, Neu suggested. “But I think we are moving forward now in a way that’s much different than the last 10 or 15 years,” he said. “And there really wasn’t a financial incentive or disincentive there [before], so that’s really started to change.”
Star ratings are taking on a greater degree of importance, noted Tripp Logan, Senior Performance Consultant at MedHere Today, during a continuing education session on “The Evolution of Star Ratings,” at Good Neighbor Pharmacy’s ThoughtSpot 2015. “Studies have been done to show that if a family member or Medicare beneficiary are looking for a Medicare Part D plan, [the Star rating] is a big deal,” he said. “On the flip side, if you have a low-performing icon on the plan finder, for Medicare Part D plans that have had three years in a row of poor performance, this is a deterrent.” The Centers for Medicare and Medicaid Services is attempting to weed out poor performers, Logan said. And that means those plans with Star measures will look for partners who can help them move the outcomes needle toward better performance.
Pharmacists can help with many of the known problems in the current healthcare system, noted Anne Burns, VP Professional Affairs of the American Pharmacists Association during a CE session titled “National Initiatives to Advance Pharmacist’s Patient Care Services.” “When pharmacists are involved, access is increased, quality is improved and costs are reduced,” she said. Access increases by tapping a health profession that’s ready and willing to help address the primary care provider shortage; quality is improved as more seniors turn to prescription medications to help manage their chronic conditions; and costs are better managed as pharmacists play a greater role in helping to manage those medications.
One key strategy to improving Star ratings is collaborating with local physician groups on patient care, as outlined by Marc Sweeney, CEO Profero Team and dean and professor of Cedarville University School of Pharmacy during his ThoughtSpot CE presentation titled, “Improvement of Patient Outcomes Through Physician-Pharmacist Collaboration.”
“My general tips for beginning these types of practices is to start with one service and expand,” Sweeney said. “Do whatever is really easy to get off the ground [like hypertension],” he said. “The number of patients who have hypertension, the medication management of it, you can assess their blood pressure and you can make a dose adjustment on their hypertensive med relatively quickly.”
According to Teresa Ash, Manager of The Medication Management Clinics at St. Rita’s at Mercy Health in Lima, Ohio, high blood pressure costs the U.S. healthcare system as much as $46 billion each year. In her CE presentation titled, “Blood Pressure Management Trying to Hit a Moving Target,” Ash noted that better controlled blood pressure ratings could result in a 35% to 40% reduction in risk of stroke, and a greater than 50% reduction in risk of heart failure.
Other opportunities Good Neighbor Pharmacy members have in linking solid outcomes to their respective pharmacy practices include incorporating a long-term care facilities service into the practice as a consultant pharmacist. Charles Mosler, professor of pharmacy practice for the University of Findlay College of Pharmacy, who moderated a continuing education course titled “The Consultant Pharmacist in Medication Regiment Review in Long-Term Care Facilities” at ThoughtSpot 2015, identified five key resources for pharmacists interested in LTC.
“If you want to get more involved with consultant pharmacy or help train new consultant pharmacists, these are the five resources that I’d really push people to [review],” he said, including the website at the Centers for Medicare and Medicaid, the Nursing Facility Survey and Regulations on www.ascp.com and TR Clark’s “Introduction to the medication regimen review,” which comes in three parts.