A Payer Has Expressed Interest in Our Enhanced Services Network: Now What?


A paradigm shift is occurring within the health care system, moving from quantity-driven to quality-driven.

Install the engine. Install the hood. Install the wheels. In December 1913, Henry Ford revolutionized the automobile industry by introducing the assembly line to American factories, In many ways, this concept has been applied to community-based pharmacies over the years. We have trained staff to excel in their sole duties in the prescription process: inputting, counting, and verifying. And down the line the prescription moves.

This method might work well in a quantity-driven environment, but in an industry rampant with direct and indirect remuneration fees and reduced product reimbursement rates, quantity-driven pharmacy production just means commoditized products dispensed faster and more efficiently.

However, a paradigm shift is occurring within the health care system, moving from quantity-driven to quality-driven. Community-based pharmacy enhanced services networks have been forming throughout the country over the past few years with a strong focus on patient outcomes and coordination of care. Thus, these networks can leverage their ability to reduce overall health care costs by contracting with accountable-care organizations, health systems, and payers. However, these payers will measure success and reimburse providers, pharmacists included, based on key performance metrics. In other words, payment is tied to the ability of pharmacists to provide quality and reduce overall health care costs, otherwise known as value-based reimbursement.

Many pharmacists may be uncertain of their ability to adjust their practices to prepare for these new opportunities, affect performance metrics, or engage patients and providers in a way that challenges norms. They may be concerned about being “held accountable” to performance metrics and patient outcomes because these weren’t required of them in the past. To succeed in this evolving health care system, pharmacists must transform their practices beyond efficient product distribution. It is important now to devote more time and training to re-engineering processes within the community-based practice that supports and promotes patient-centered care and quality-driven practices. Implementing new workflow processes takes time, but there are 4 key tips to start transforming a pharmacy to a value-based care model.

1. Change the culture. Historically, the industry has focused on filling as many prescriptions as possible and dispensing quickly, accurately, and cheaply. However, everyone working in a pharmacy must embrace the culture shift from merely focusing on prescriptions to focusing on patients. A community-based pharmacy practice that has embraced these new concepts of value-based care and high performance on quality metrics must embrace a new practice paradigm. In this new paradigm, pharmacists are freed up to perform enhanced clinical services with patients. This requires optimizing efficiencies within the pharmacy by using technicians to drive the dispensing processes, implementing medication synchronization processes, and using automation and technology. It takes a team effort to be successful.

Operating as a team within the pharmacy seems simple, but it is often the most difficult yet critical aspect to ensuring success in a value-based care model. Even for those who see the vision, challenges may arise when educating staff members on the mission of quality-driven care. All staff members must understand their role in the pharmacy. It comes down to maximizing every patient encounter and recognizing gaps in care. Help the staff understand that when Mr. Jones calls every other day for refills, he would benefit from medication synchronization. Help them understand that when Ms. Parker says that she forgets to take her blood pressure medications, she would benefit from adherence packaging. When Ms. Brown comes into the pharmacy after her prescriptions have been sitting in will call all week because she couldn’t find a way to get there, she would benefit from delivery service. More complex barriers may also require coordination with care managers and other members of the health care team.

2. Integrate coordination of care. Pharmacies will not be able to meet key performance indicators unless they integrate themselves within the health care team. Traditional pharmacy-based metrics have focused primarily on medication use and adherence rates. However, successful performance in a value-based care model includes much more than these specific medication-related metrics. Pharmacists need to ask 3 questions during encounters with patients: Have they achieved their therapeutic outcomes? Are their medications safe? Are their medications effective? If the pharmacists answer “no” or “I don’t know,” then there is a potential medication-related issue.

Pharmacists must become interventionists when they identify medication-related problems, providing clinical recommendations to prescribers and other providers to ensure that patients are achieving their therapeutic outcomes. This may include recommending additional medications, discontinuing medications, or changing doses.

Developing relationships with local prescribers allows for the bidirectional exchange of information. Demonstrating the value of pharmacy services fosters these partnerships. The bottom line is to identify partners in the community that want to work with the pharmacist in this capacity. Make them understand that pharmacy services include much more than dispensing alone.

Beyond clinical metrics, pharmacists are also responsible, like other providers, for controlling health care use and costs for patients. This means making sure that patients are optimally treated with safe and effective medications to reduce emergency department visits, hospitalizations, and excessive use of overall health care resources. Also, pharmacists must ensure smooth transitions of care for patients by providing medication reconciliation services and communicating closely with other providers to resolve medication irregularities. Finally, community-based pharmacists must also identify gaps or disparities in care during patient encounters. Once the disparities are recognized, it becomes important to understand the reasons why these gaps exist—such as lack of provider access to patient information, lack of patient access to appropriate health care providers, lack of patient engagement, and lack of care coordination. Developing strategies to reduce the gaps can improve care efficiencies and costs.

3. Focus on high-risk patients. From a payer perspective, high-risk patients are the costliest. Therefore, this may be a population that community-based pharmacists can have the most impact on both clinically and financially. This strategy, commonly called population health management, should be a focus for pharmacists.

In North Carolina, the highest-risk patients are age 62 on average, typically fill 10 prescriptions per month, and have at least 3 chronic conditions. These complex, chronically ill patients need assistance navigating the health care system. Pharmacists can potentially have the most impact on these patients by ensuring appropriate therapy and attainment of therapeutic goals, adherence to therapy, optimizing patient outcomes, and reducing overall health care use.

Consider data mining to identify these patients. Adherence is one of the easier metrics to tackle. Work with dispensing software or other vendors to develop reports that highlight patients with less than 80% adherence. Engage these patients to determine barriers to adherence, and use motivational interviewing to develop patient-centered goals. Enroll these patients in a medication synchronization program to improve adherence and, more important, decrease consequences associated with non-adherence such as hospital admissions.

Once a pharmacist has a handle on approaching non-adherence, he or she should begin to focus on more difficult outcome-based metrics that are more related to appropriateness of therapy (eg, statin therapy in patients with diabetes), the need for additional therapy (eg, the use of controller therapy in patients with asthma), or appropriate dose (eg, statin intensity level based on patients’ 10-year risk of cardiovascular risk). Pharmacists can consider offering disease state management classes, administering long-acting anti-psychotic injections, educating patients when to use the primary care office versus the emergency department, and providing comprehensive medication reviews with chronic-care management. Customize the pharmacy’s service sets to the population served to achieve better outcomes, thereby helping the pharmacy meet corresponding quality-based metrics.

4. Follow up. This is key. Historically, pharmacies are engineered for episodic care: A patient presents a prescription, and there is an efficient system in place for getting the individual with the filled prescription out the door as quickly as possible. But then what? Does it matter if that medication worked? Has the patient’s health improved? Community-based pharmacists need to re-engineer their workflow to accommodate chronic care, not just episodic care. High-performing pharmacies have clinical medication synchronization in place so that the dispensing of medications is aligned with medication and disease state management. In this way, pharmacies can continuously evaluate the safety and efficacy of therapy as well as barriers to care. Remember, chronic-care management means constant-care management. To successfully implement this component, a pharmacist may want to delegate follow-up duties to a member of the pharmacy staff. Monthly follow-up calls for complex patients and calls to a patient after the initial fill of a new chronic medication are a couple of examples. Some pharmacies have implemented a community-based antibiotic stewardship program in which patients are called a few days after an antibiotic is started to ensure the proper course of therapy, safety, and efficacy. Ongoing monitoring and follow-up with patients is essential to successfully caring for patients.

Start somewhere. By stepping out of our roles of pushing the prescription down the assembly line month after month, we are empowered to make a much larger impact on patients’ health. Value-based care models improve patient outcomes and create a marketplace presence for pharmacies that go above and beyond for patients. Implementing innovative strategies to achieve quality-based metrics will allow pharmacies to continue to drive forward and compete in a value-based marketplace.

Randy P. McDonough, PharmD, MS, CGP, BCPS, FAPhA, is the co-owner and director of clinical services at Towncrest and Solon Towncrest Pharmacies, Towncrest Compounding Pharmacy, and Innovative Pharmacy Solutions.Shannon Rudolph, PharmD, is a graduate of University at Buffalo and completed her PGY-1 Community Pharmacy Residency at UNC Eshelman School of Pharmacy with Moose Pharmacy in Concord, North Carolina. She currently serves as the Executive Fellow at the Iowa Pharmacy Association.

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