The emergence of a new Medicare Advantage plan, Troy Medicare, offers much needed momentum to drive pharmacists’ services.
For decades, community pharmacists have been seeking new models of compensation for clinical services, especially as the training they receive has shifted towards a focus on patient care, and in-depth clinical decision-making. These readily available health care professionals have the potential to play a critical role in the care of the patients they see every month, but widespread change from a focus on dispensing has yet to occur.
The meticulous and time-intensive nature of dispensing a high volume of prescriptions every day takes too much of the pharmacist’s time, yet prescription volume remains the main revenue driver. Further, even if pharmacists had the time, their access to usable patient data is very limited, making it difficult to know which patients to focus on, or how to best care for them. Finally, and most critically, payers and health plans have been traditionally unwilling to pay pharmacists enough to make it a sound business decision for them to spend a significant amount of time caring for patients.
Overall payer hesitation appears unrelated to the need for proof of pharmacists’ value in managing chronic disease. In fact, this body of evidence has grown so large it is hard to refute.1-3 The main impediment is scalability—if payments for patient care services were implemented at scale, would pharmacists across the country collectively have the ability to change their day-to-day workflow, spend time with patients, and manage medications for populations the way they are trained? While it would be a disruptive change in the United States’ primary care delivery model, there exists enormous potential for pharmacists to mitigate the burden of chronic disease—the largest driver of morbidity, mortality, and cost in US health care (~96-99% of Medicare spending).4-6
In recent years, there has been significant progress to improve the efficiency of dispensing activities through automation, theoretically giving pharmacists more time to perform clinical activities. The appointment-based model has gained traction as a way for pharmacies to transition their care process to a more proactive approach. There have also been significant grassroots efforts, such as the Community Pharmacy Enhanced Services Network (CPESN), to increase the level of service expected from a community pharmacy, particularly for independents and small chains. With these advancements, in a time where many pharmacies are desperately in search of new revenue channels, due to shrinking dispensing margins, perhaps pharmacies are willing to accept the risk of adopting a new care model in their practices.
The emergence of a new Medicare Advantage plan, Troy Medicare, offers much needed momentum to drive pharmacists’ services. Troy’s model puts pharmacists in the driver’s seat of chronic care, namely by including per-member-per-month payments of $30-$50 to pharmacies that fill prescriptions and provide pharmacy services for their members. Troy will also provide technology that enables pharmacists to have a clear view into patients’ healthcare history, as well as interoperable communication of pharmacy care plans (eCare Plan) between healthcare settings. Through these solutions and a pharmacy-friendly reimbursement model that uses NADAC pricing, imposes no DIR fees, and provides flat dispensing fees, Troy hopes to increase transparency and support pharmacies as a business. More broadly, this model intends to leverage pharmacists’ expertise as chronic care managers in order to improve seniors’ outcomes and lower total cost of care.
As a first of its kind, Troy Medicare has emerged at an opportune time, offering financial flexibility that pharmacists and pharmacies have been seeking. Service-based revenue will enable more pharmacies to invest in needed technology, and become much more invested in care delivery. Pharmacists’ ability to regularly and meaningfully engage with patients to improve their care is not only more gratifying for pharmacists, it is a lower cost option for high quality chronic disease management.
Nonoptimized medications are an immense driver of avoidable cost in US health care (>$500 billion/year)7, and the pharmacist’s training, knowledge, and skill are precisely oriented to the management of complex medication regimens for patients with chronic disease, more so than any other health care professional, including physicians. Perhaps we are approaching pharmacy’s perfect storm—a convergence of factors that will serve as a catalyst for societal change in the way chronic medication management is delivered.
As outcomes-based payments, and quality measures continue to strongly influence provider reimbursement, community pharmacies positioned as integral members of the health care team will become indispensable. Troy’s model provides an ideal environment for this transition to reach critical mass.
By simply facilitating a model in which pharmacists can focus less on filling prescriptions, and more on filling their intended role, reimbursement models like Troy’s could be the force needed to pull the linchpin in pharmacy’s long-awaited disruption.