Understanding the Shift to Value-Based Care for Pharmacy, Part I

Value-based care. Not a new term in healthcare, or even clinical pharmacy, but a current buzzword across the industry today, especially as more commercial payors buy into the concept. In this two-part blog series we’ll explore this buzzword even more as we look closely at how payors define it, why it’s worth considering, how it can work in pharmacies and what benefits pharmacies and patients can expect.

What is pharmacy value-based care?

The term value-based care refers to a form of reimbursement that directly links payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness.

Improving patient outcomes has always been at the core of why pharmacists do what they do. Beyond the HEDIS score, pharmacists work hard every day to assist their patients in building healthier lives, which is why they went into the profession in the first place.

How do payors define value-based care?

For CMS, “Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for.”

From a payor perspective, better outcomes equate to healthier patients and lower costs. Due to the powerful tie to outcomes, value-based care gives payors a way to ensure provider accountability.

So what exactly makes pharmacy-driven value-based care such an attractive proposition to payors? Two things. Outcomes and accountability.

And with the natural expansion of pharmacy into more clinical services, the outcome-driven accountability that comes with value-based care creates a win-win situation.

Why value-based care in pharmacy now?

Why now? What made 2022 the year of value-based care? And why will it continue to be a key trend in 2023? Pharmacy and pharmacists are finally getting closer to full provider status in the eyes of the commercial payor, for one. Especially with the recent developments around Test-to-Treat. And secondly, as the consumer-driven economy demands more accessible sources of healthcare, pharmacy and value-based care seem like a very natural evolution. 

Shift Test-to-Treat into Hyperdrive.

To get caught up on what’s currently happening in the Test-to-Treat landscape, check out our webinar with Drug Store News.

Why your pharmacy needs a plan for value-based care: 

  • Value-based care creates better outcomes for the patient and the provider.

    In a traditional fee-for-service model, once the appointment is over both parties move on. And in the case of a simple flu test, the fee-for-service model makes sense. However, not every appointment should fit into the fee-for-service model, especially in the case of chronic condition treatment. In a value-based care model, the connection between provider and patient does not end with the appointment, leading to a deeper, trusted partnership between pharmacist and patient, while helping the patient to stay adherent, close gaps in care, and reap the benefits of better outcomes.

  • Pharmacy value-based care  drives increased opportunities for higher reimbursement.

    When pharmacists embrace value-based care, it makes it easier for them to contract and build relationships with payors, creating a smoother pathway for reimbursement of high-value clinical services. These include services for patients with chronic conditions who need support to maintain medication adherence, close gaps in care and better manage condition episodes to reduce emergency visits and hospital stays. Many of these services qualify for higher reimbursement under the CMS initiative that has quantified value-based care success under the Value Modifier program, which adjusts Medicare payments based on positive or negative quality assessments.

  • Value-based care fuels growth of the pharmacist as provider model.

    We are bending the curve of pharmacy™  right now. First came immunizations, then point-of-care-testing for COVID-19, and who knows what’s next on the horizon? Full provider status for pharmacists and pharmacy organizations?  And once full provider status is recognized, additional clinical services will fall into place for your pharmacy, building extensive clinical opportunities and revenue growth for your organization.

How does retail pharmacy adapt to value-based care workflows?

Pharmacy value-based care as a total cost of care solution

Here’s how the Pharmacy Quality Alliance (PQA) explains how value-based care can work at your pharmacy.

“A pharmacy chain connected with employers, providers and payors to educate each stakeholder group on the role pharmacists could play on the clinical care team. These education efforts led to the establishment of agreements between providers, payors, and employers in which pharmacists provided care to lower the total cost of care for patients and employers. Payors targeted patients and selected high-performing network pharmacies to deliver pharmacist-provided care. Pharmacists provided state management care and used telepharmacy to address the needs of rural patients. The pharmacies were evaluated on their performance and contribution to lowering the patients’ total cost of care compared to the previous year.” (PQA)

After taking a closer look at value-based care, hopefully you’re convinced that the opportunities outweigh the challenges.  For many organizations, implementation of a new care model means change management and stress for your pharmacy staff. But many retail pharmacies are, as mentioned above, already equipped with most of the tools needed to integrate value-based care today, making it easier than you might think to add this to your clinical offering. Learn more about value-based care pharmacy workflows and how it can benefit your pharmacy in Part II of this blog series, coming soon!

Ready to learn more about how value-based care can help grow your pharmacy business?

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