The shift from fee-for-service to a value-based care payment model represents the growing understanding of the value of health care providers in improving overall patient outcomes.
One of the most significant changes in the pharmacy landscape for 2020 lies within the shift from the standard fee-for-service model to a value-based care payment system. The shift demonstrates a increasing awareness surrounding the social determinants of health (SDoH) as well as the growing understanding of the value of health care providers in preventing hospitalizations and in improving overall patient outcomes.
Over the past 5 years, there has been a 7-fold growth in the number of states and territories implementing value-based reimbursement programs, now totaling 48 nationwide. Additionally, more than 20 states have evolved their valued-based care efforts, including recent initiatives by New York, Pennsylvania, and Vermont.1
Given the contrary impact of the fee-for-service model on the SDoH, the shift from the previous model in favor of a value-based care model is expected to continue. SDoH can save a potential $1.5 trillion dollars in health care spending, according to Healthcare IT News.2
“Pharmacies have a ton to offer in value-based care, and hopefully value-based care has a ton of opportunities for pharmacies as well, as [providers] are focused on outcomes. Both the medications and making sure those medications are appropriately used is a big part of achieving good outcomes and thus good value, which is at the core of value-based care,” Kurt Proctor, PhD, RPh, senior vice president of Strategic Initiatives at the National Community Pharmacists Association, said in an interview with Pharmacy Times.
OTC solutions are projected to transform the role of community pharmacies in patient health and health care as a whole. As added value service and revenue streams grow and adapt, retail pharmacies will grow their SDoH solutions offerings, from health screenings to connecting with patients in the SDoH continuum through food, clothing, transportation, and more.2
In an interview with Managed Healthcare Executive, Thomas R. Bizzaro, RPh, vice president of Health Policy and Industry Relations of First Databank, Inc, said that health plans investing in addressing SDoH will likely see a positive impact in areas such as medication adherence.2
“SDoH have been obvious to health care provider for many years, but the concept hasn’t been a focal point in the total care of the patient until more recently. There’s a growing recognition that not only do you need to treat physiology for disease management and prevention, but you also need to identify whether members need help with social care that can affect their well-being and clinical outcomes—including those related to pharmacology,” Bizzaro told Managed Healthcare Executive.3
Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.4
Value-based care is understood by health care providers as a means for reimbursement for the enhanced services that they are positioned to give patients in order to address SDoH. These payment programs support a 3-part aim: better care for individuals, better health for populations, and lower costs.3
To Proctor, pharmacists who lead the way in documenting their enhanced services through blood pressure monitoring or A1C, as well as addressing the changing terminology in the health care landscape, will have the greatest impact.
“We have to recognize the contribution of value that we have, but we also have to understand that we’re not going to be recognized for that on the payer’s side of the equation if we’re not documenting what we’re doing,” Proctor told Pharmacy Times. “[Providers] wouldn’t think for 1 second if they didn’t document a prescription, but we’re not going to be paid for our services and care if we don’t document it. So, we need to change our orientations. Then, that documented care will make the case to the payer’s side that pharmacists have an important role to play in value-based care.”
Community pharmacists have been addressing the SDoH for years, working as vital members of their communities by interacting with patients every day. Using training programs that formalize these roles will ultimately benefit the pharmacy staff and patients as a whole.
One way to do this is through collaboration with integrated delivery networks. Proctor explained that once NCPA brought together pharmacists in integrated health delivery networks with community pharmacists from their area, collaboration improved.
“Upon recognizing that they share patients, but that they never talk to each other and do not coordinate, they immediately took off and discussed ways that they could work together and what access to whose data and sharing information,” Proctor told Pharmacy Times. “It was really encouraging to see. It’s just a matter of a realization that these community pharmacists exist, that they’re seeing the same patients that are seen in the integrated delivery networks and share the same desire for possible outcomes for these patients.”
Ultimately, it is not a matter of abandoning dispensing, Proctor noted, but rather understanding that there is a greater need to address the patients’ overall health outcome through collaboration.
“It’s important to know that the day will come that delivering on these patient care activities and achieving these outcomes is what will give pharmacies the privilege to dispensing those prescriptions,” Proctor told Pharmacy Times. “Payers are going to want their patients going to those providers whose patients are achieving positive outcomes, the lower total health care cost. That’s what will maintain the privilege of dispensing those medications, is patients achieving those kinds of outcomes.”