Quality over quantity: How value-based care is reshaping the pharmacy

Perspective: Insights-driven outcomes | Capability: Pharmacy | By: Carelon

In many communities, independent pharmacists can propel value-based care toward success. More healthcare leaders are recognizing the vital role they play today in value-based care — and the transformative benefits that they can yield.

Value-based incentives have gained momentum across the healthcare system. Yet the possibility for greater adoption remains. For example, a 2022 report from JAMA Health Forum  revealed that compensation of most health-system physicians is still based on volume-oriented metrics, such as patient or procedure volume, rather than quality-oriented measures.

This pivot toward value over volume, along with a growing shortage of primary and specialty care physicians , makes independent, community pharmacies crucial to the future of value-based care. Especially since the COVID-19 pandemic, they have become a source of trust and connection within their communities.

Future-forward healthcare organizations have taken notice of these clinicians’ role and value in communities. And they are proactively working to integrate them in their value-based care strategy.


What makes pharmacists so critical to value-based care strategies?


Improving affordability and outcomes often involves addressing the impact of drugs on healthcare costs. Pharmacists play a critical role in this equation. Pharmacists help ensure safe and appropriate medication use — an important task given that drugs account for around 15% of total U.S. healthcare spending , which reached $577 billion in 2021, a 7.7% increase from the previous year.

Pharmacists are also often one of the most accessible clinicians within the healthcare system. Nearly 90% of individuals in America live within a 5-mile radius of a pharmacy . And with almost 50% of individuals  having used prescription drugs in the last month, pharmacies can be one of the most-visited care settings within the healthcare system.

According to Stacey Decembrele, Staff Vice President of Pharmacy Network Management and Strategy at CarelonRx, these trends position independent, community pharmacies as an essential partner during seemingly every healthcare journey.

“Pharmacies cater to a diverse spectrum of patients,” Decembrele said, “including high-risk individuals, the medically underserved, and those facing social inequities and care barriers. In certain regions, community pharmacists are effectively bridging the gap caused by the shortage of primary care physicians.”

Decembrele noted that certain value-based contracts, such Medicaid contracts, even enable pharmacists to “provide services beyond the basics, such as behavioral health assessments, biometric screenings, and health coaching.”

As more progressive organizations think differently about the value independent, community pharmacies offer, many are turning to pharmacy benefit managers (PBMs) to drive the value-based partnerships with these local pharmacies.

PBMs can identify quality provider networks in their market that excel in improving outcomes. They also facilitate reimbursement for their providers' engagement in enhanced patient-care activities, like a focus on the quality measures.


Tapping the power of quality measures


Quality measures empower providers to deliver high-quality care through collaboration and personalization.

In pharmacy, PBMs use provider scorecards to integrate quality measures into established pharmacy practices. These scorecards typically assess clinician performance against established quality benchmarks, such as HEDIS measures or performance measures set by the Pharmacy Quality Alliance.

Provider scorecards offer a metric-centric review of performance, covering numerous dimensions, such as:

  • Clinical outcomes
  • Patient satisfaction
  • Alignment with clinical guidelines
  • Patient safety
  • Efficiency
  • Financial factors.

While provider scorecards often offer feedback on individual patient health and provider performance, they also contribute to broader goals, like population health management and care coordination.

For example, CarelonRx's approach connects health plans’ goals with provider competencies. Collaboration with state Medicaid plans sheds light on this approach.

"HEDIS quality measures, established for each state Medicaid plan, outline thresholds for key areas of care that result in significantly more or less funding depending on if plan goals are met," explained Decembrele. "We look at programs that Medicaid plans have in place, and then evaluate how our independent, community pharmacy initiatives can complement those and address unmet patient needs with additional support."

This format elevates pharmacy quality and addresses financial goals for Medicaid plans, resulting in mutual benefits while enhancing health and satisfaction outcomes.


Bringing providers together, side-by-side


Pharmacy quality measures alone cannot elevate care standards, especially when members interact with providers who adhere to different metrics. Creating a unified care model that emphasizes interdisciplinary collaboration among healthcare professionals is also crucial. Meaningful provider engagement occurs when healthcare organizations, through PBMs, take an active role in collaborating with pharmacists and other healthcare providers. In value-based care models, a growing focus involves healthcare providers and pharmacists who are specially trained to identify care gaps, enact whole-health care plans, and deliver clinically appropriate care. PBMs help facilitate these seamless connections among different clinicians to achieve those goals.

For instance, CarelonRx offers a Provider Quality Incentive Program (PQIP), which rewards providers for delivering high-quality and cost-effective healthcare to Medicaid members. What’s been the common denominator for many successful PQIP experiences? Interdisciplinary engagement.

"Integrated platforms between different healthcare entities allow prescribers to see the action plans, care gaps, and cost-effective opportunities their patients have in relation to pharmacy,” noted Decembrele. “We also have a prescriber-facing pharmacy team that connects with those practitioners, as helping manage those plans, gaps, and costs impacts the pharmacy value-based contracts."

By design, the value-driven contracts implemented by CarelonRx promote collaboration among practitioner groups, thereby reducing costs and outcomes.


The future of value-based pharmacy care is local


Healthcare is local, the saying goes. As innovators at healthcare organizations recognize the power of independent, community pharmacists, a new take on that observation will likely arise: value-based pharmacy care is local. To Decembrele, there’s no question it will be.

"The local, community feel of the pharmacy provides more ways to engage with patients than other healthcare practice areas. Leveraging these interactions through value-based care allows local, independent pharmacies to drive patient and payer goals, including improved health outcomes, reduced primary care visits, reduced hospitalizations, and reduced healthcare costs overall."


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