Technology in Action: Ushering in Streamlined Reimbursement


The nature of pharmacy reimbursement in changing, shifting from the standard fee-for-service, 'fill-and-bill' model to a patient-centric, value-based system. However, the transition between these 2 means of revenue is often confusing and frustrating for independent pharmacists.

The nature of pharmacy reimbursement is changing, shifting from the standard fee-for-service, 'fill-and-bill' model to a patient-centric, value-based system. However, the transition between these 2 means of revenue is often confusing and frustrating for independent pharmacists.

To assist these pharmacists, FDS Inc. has made its goal to usher in a “New Era Pharmacy,” one that includes healthy business models and solutions that aim to be more simple and effective than current reimbursement models.

There are approximately 22,000 independent community pharmacies in the United States that represent a market of $77.6 billion. According to the 2018 NCPA Digest, these pharmacies get a full 92% of their revenue from prescription drug sales. This means these pharmacies have 2 problems: they take a hit if insurance companies fail to pay them, and there is a need to build out additional revenue streams to reduce dependence on the 'fill and bill' model.

According to FDS, the company provides software solutions to over 12,000 independent pharmacies in the United States. It has situated its technology platforms in 3 distinct areas: financial (Econcile), analytics (MyDataMart), and consumer (Engage). This portfolio strives to be mindful of what it means to be successful, often including financial and billing management, a reconciliation platform, and a medical billing solution that is simple and effective, according to the company.

Last year, FDS Inc. helped its customers collect $40 billion in reimbursements, according to the company. In addition, they provided community pharmacies with easier reimbursement plans, improved adherence, increased revenue and growth, and, ultimately, meaningful patient care.

“We think that pharmacies are incredibly well situated to do integrate medication and patient care, since they’ve been giving care [that’s] been subsidized by the Rx distribution model,” said Adam McMullin, CEO of FDS, in an interview with Pharmacy Times. “As you move to this new model […] you need to understand what your patients need, at what time.”

And the need is there. According to Benjamin McNabb, owner and pharmacist of Love Oak Pharmacy in Eastland, TX, aggressive motivators such as the DIR system make it essential for pharmacists to diversify their patient care models. Technology solutions are helping to change that motivation to patient- and pharmacist-first.

“The industry has emerging value-based payment models where pharmacies can be paid for providing enhanced services like disease management, including trackable outcomes such as emergency room visit reductions,” said McNabb. “[Hopefully], we can find additional value in those outcomes, and that there will be new motivators to once again that put independents ahead in the industry, where quality is the what matters the most, not how fast, accurately, and cheaply we can fill meds.”

In this value-based reimbursement model, medical billing is slowly becoming more prominent as a form of payment for pharmacists. eCare plans, like those from FDS Inc., will allow community pharmacists to increase potential revenue through immunization options, medication synchronization, and more. Data-driven technology can influence the opportunities that pharmacists have in terms of patient care. Furthermore, it can lead pharmacists to appropriate documentation and billing arrangements.

“Through our analytics portfolio, we mine the data that’s inside the pharmacy, and we enable the pharmacist to be proactive and reactive in their work flow for patients who may not be compliant with their prescriptions.,” said Peter Fianu, CIO of FDS Inc. “Perhaps there are patients missing in the operations. We help them identify those patients and bring them back into the pharmacy. We help them understand what patients are late to fill, and why.”

McNabb recently implemented the FDS in his pharmacy and found that it greatly improved medication adherence. “As we’re working through these clinical services, many of these models appear to be going toward the direction of the per-member-per month to give pharmacies up-front payments to interact with patients in outcome driven ways,” he said.

“To enter into these peer-relationships, you need a clinical documentation system to prove that the pharmacy is doing the work, but also potentially communicating back to the health systems, such as social determinants of health, but also coordination with the health plan. So, the communication tool is vital," McNabb added.

All in all, FDS helped Love Oak Pharmacy, report over $500,000 in additional revenue by leveraging data from RxCOMPASS through the FDS MyDataMart. McNabb was also recognized with NCPA’s Outstanding Adherence Award in 2018.

The “New Era Pharmacy” ultimately centers around the pharmacist, company officials said, and their solutions are a means to free up time for pharmacists to get back to what matters: the patient.

“We spend a lot of time making sure that we have technology that makes the store more efficient, “ said Fianu. “If we can help those pharmacies get the extra time to spend with patients, then we’ve been successful.”

FDS is currently working on unlocking data that is currently in the pharmacy to give pharmacists a greater view of their store and patients. The company is also working on a solution to allow pharmacists to compare how their pharmacy may be performing in relative to their peers.


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