Evaluating Payer Programs Available for Community Pharmacies

Kelli Stovall

Hello! Thank you for joining us today for Evaluating Payer Programs Available for Community Pharmacies? Today, we are so excited to discuss building sustainable revenue through performance-based care.

I’m Kelly Stovall and I get the great opportunity to serve as the Vice President of Clinical Strategy and Pharmacy Advancement at IPC. A little bit about this program. It is ACPE accredited and has been approved for one hour of continuing education for pharmacists and pharmacy technicians.

Rosalyn. First, I’d like to introduce our two guest faculty speakers today. We’re so excited to have Rosalyn Otting and Blair Thielemeyer.

Rosalyn is the Senior Manager of Clinical Transformation at PQS by Innovaccer, where she serves as quality measure subject matter expert focused on pharmacy quality measures and clinical program development. She draws on over a decade of clinical experience in value-based and performance-driven pharmacy care. Blair is a pharmacy leader with experience designing, implementing, and scaling clinical services on the PQS by Innovaccer team.

She helps independent community pharmacies integrate clinical services into their daily workflow, and she’s also recognized for her work advancing pharmacist-led care models, medical billing, and the practical integration of clinical programs into daily pharmacy workflow. Next slide. So, a few disclosures to get us started.

Our speakers today have no relevant financial relationships with ineligible companies to disclose, and funding for this course was provided by Independent Pharmacy Cooperative. One thing I’d like to say throughout the… throughout the program, please feel free to enter questions along the way. We have a Q&A tab below that you can click on and enter your question, and we’ll be monitoring that throughout the program, and we’ll address those questions at the end.

Next slide. So let’s take a look quickly at our learning objectives. Today, our learning objectives are describe Payer program opportunities available to community pharmacies within the current value-based care landscape.

Explain how pharmacy performance measures, Medicare star ratings, and payer quality incentives may affect pharmacy performance, reimbursement, and revenue opportunities. Recognize best practices for implementing and sustaining performance-based clinical programs within community pharmacy workflows. And lastly, identify strategies for pharmacy teams to use to support performance improvement and engagement with Payer Programs.

Next slide. We’ve included a slide on acronyms and abbreviations referenced in this program for your convenience, and now Rosalyn will get us started.

Rosalyn Otting

Okay, thank you so much, Kelly, and may I wish everyone here a happy Pharmacist Month, if you’re on the call. It’s a pleasure to be here today with you all to talk to you a little bit about value-based care and performance-based care in the pharmacy realm. I know that this is something that we’re all seeing more in practice today as payers are rolling out clinical programs and performance based incentives to pharmacies.

So we have a really great deck today, and I hope all of you will be able to leave with some new knowledge to help you leverage performance-based care to build revenue for your pharmacies. I’ll be starting us off today, and in my section, we’ll go over a brief history of value-based care in the United States. We’re going to talk about performance measures as they relate to pharmacy.

We’ll break down Medicare Advantage and the STAR rating program, and we’ll look at specific payer programs that are available to pharmacies today. After that, I’ll pass it over to Blair, who will talk to you about key strategies for implementing and sustaining clinical programs in community pharmacies and then finally I’ll hand it back to Kelly to talk to you about developing an adherence champion at your pharmacy. But first, before I begin, let’s start with our first knowledge check.

Okay, so let’s test your knowledge. For these questions today, you can go ahead and put your answers in our chat box, and the first question is. Which legislation accelerated the national shift from volume-based reimbursement to value-based care and led to programs such as MIPS, which is the Merit-Based Incentive Payment System, and alternative payment models like accountable care organizations?

A, Medicare Modernization Act, B, Affordable Care Act, C, MACRA, which is the Medicare Access and CHIP Reauthorization Act, or D, HIPAA, Health Insurance Portability and Accountability Act. So go ahead and throw your answers in the chat. Do we have any answers coming in?

Just want to make sure our chat is working. Okay, well, if you don’t know, or if our chat is not working.

Kelli Stovall

Hold on, we do have… Joe, it says our chat’s disabled. Well, we’ll try to get that fixed.

Rosalyn Otting

Okay, we’ll get it fixed for the next one. But for those of you who knew it, the answer is going to be. C, MACRA.

Okay, so let’s move to our next slide. We’ll talk a little bit about the history and the timeline of regulatory changes that have moved us from a fee-for-service model to a value-based or performance-based model that we’re seeing in current practice today. So first, let’s roll back the clock to the 1990s.

For those of us that were around back then, when fee-for-service was the primary practice model, and with fee-for-service models, providers are incentivized to bill for as many services as possible to maximize revenue. Unfortunately, what we learned from this is that quantity of care does not always equal quality of care, so we’re spending more than ever and not seeing improved patient health or outcomes. In 2003, CMS passes the Medicare Modernization Act, which establishes Medicare Advantage, Part D, and lays the framework for value-based care.

Moving forward to 2010, Congress passes the Affordable Care Act, which replaces the traditional fee-for-service model with a reimbursement model tied to patient outcomes, reduced readmissions, and preventive health. Then the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, as previously noted, further drives the transition to value-based care by establishing the Quality Payment Program, which defines quality reimbursement payment models for Part B through MIPS and alternative payment models like accountable care organizations. That brings us to 2016, the year that PBMs began implementing retroactive DIR fees.

So there was a small loophole in the 2014 final rule. That allowed PBMs to apply the retroactive clawbacks tied to a pharmacy’s clinical and quality performance scores. So that marked the beginning of the push towards performance-based reimbursement in pharmacy.

In 2017, CMS establishes Meaningful Measures 1.0, which endeavors to reduce the number of quality measures and focus on meaningful outcomes. They then further expand on the initiative in 2021 to include a focus on equity and the transition to digital quality measures. In 2022, CMS formalizes the National Quality Strategy, which defines broad, overarching quality domains at a national level.

And then finally, after many years of passionate advocacy, we end in 2024, where CMS eliminates the retroactive DIR fees and mandates that all pharmacy price concessions must be applied proactively at the point of sale. So this change is the driver that has kind of forced payers to transition toward quality-based financial incentives that we see tied to pharmacy performance today. So why did the industry make such a big push away from fee-for-service and towards value-based care?

So on this slide, you can see that the backbone of value-based care is the Triple Aim. The Triple Aim is a framework developed by the Institute for Healthcare Improvement in 2008 that believes if you provide high-quality care, you’re going to improve patient health. Which will then allow you to spend more money to provide high-quality care.

In 2014, this model was expanded upon to the quadruple aim, which also includes considerations for clinical and staff well-being, and again, updated in 2021 to include considerations for advanced health equity. So with that background overview, let’s dig in a little bit more about the measures themselves that are most impactful to pharmacy performance and reimbursement. We’re going to start this section with another knowledge check.

Again, please enter your answers in the chat box, and it does appear to be working this time. The question states, a quality measure steward is best defined as… A, an organization that pays pharmacies for performance. B, a payer that administers star ratings.

C, an organization that owns and maintains quality performance measures. Or D, a pharmacy network that negotiates contracts. So go ahead and put your answers in the chat.

Seeing some answers come in. Looking really good? I think we’re on the same page here.

The answer is C, an organization that owns and maintains quality performance measures. All right, so Performance Measures 101. So there is a lot of information on this slide, and I definitely want to leave enough time at the end of this presentation for questions, so I’ll just give a brief overview of the performance measures here.

Performance measures, or quality measures, are maintained and designed by measure stewards. They are defined for use as part of measure sets. Which then tied to performance outcomes in measure programs.

So, we can look at an example from this slide. The Pharmacy Quality Alliance, or PQA, is the measure steward that maintains the pharmacy measures you are likely the most familiar with, like the medication adherence measures. The PQA measures look at four domains, including appropriate use, safety, adherence, and medication management services.

PQA maintains its own measure set, but measures that they define are also used in other programs, like the Medicare Star Rating measure sets. The Star Rating measure sets are then used to calculate performance scores as part of the Medicare Star Rating program. The other most relevant group on this slide that I’ll reference throughout the presentation is the National Committee for Quality Assurance, or NCQA, which maintains the healthcare effectiveness data and information set called HEDIS.

The HEDIS measure set is what’s used within the Medicare Star Ratings Part C domain. So when we talk about performance measures, we often use the term PDC, which stands for proportion of days covered. This is the key measurement used to define adherence as defined by PQA, and it’s calculated by the equation you can see at the top of the slide here.

So to determine PDC rates, you count the total number of days covered by a prescription fill divided by the total number of days in the measurement period, and then you multiply it by 100 to get percentage. So CMS uses a goal of 80% PDC to determine if a patient is adherent or non-adherent. So adherence is a nominal data point.

Your patients are either adherent or they’re not. So the nominal adherence data is then used to determine cut points for quality measures, which tie back to a planned star rating score. And cut points are pretty interesting because they change from year to year.

When CMS assesses performance data, they use the data to score it as if it were a bell curve. So even if all of the plans on the market are performing really well, only the best of the best plans are going to get the top ratings of four and a half and five stars. So between years, plans may have different goals for adherence due to changes in the star rating cut points.

But the nice thing about PDC is that your patients don’t have to be 100% adherent to be considered adherent in a quality measure. So the calculations take into account the human factor with that goal of 80%. We know it’s not really realistic to expect perfection from our patients in this aspect.

So that’s one nice thing about PDC and adherence data points. Another notable thing on this slide is the term IPSD, which stands for Index Prescription Start Date. The IPSD is the first day of the fill of the medication during the measurement period, so you aren’t assessed for any days prior to the first fill in the measurement year.

The measurement period can end in three ways. It can end at the end of the year when a patient loses coverage or if the patient passes away. So, this calculation also accounts for overlap of prescriptions, so if you fill a refill early before it’s due, you’re still going to receive credit for those overlapping days.

Here you can see the key performance measures that impact the day-to-day pharmacy activities. The first three that you may be the most familiar with are the medication adherence measures, which are the Part D measures using the PDC methodology. For PDC, your patients are considered adherent, again, if they have 80% or more of days covered by the medication.

The numerator is the adherent patients, the denominator is total patient population. And the pharmacy’s role for these measures is to utilize existing programs to improve performance, things like MedSync, refill reminders, adherence support, and other things that may work for your group. So, controlling blood pressure and diabetes care blood sugar control are the next two on the list, and they’re both HEDIS measures that are incorporated into the Medicare Stars Part C domain.

So, pharmacy point-of-care data for blood pressure and A1C readings can be used by payers to meet these measures and close care gaps. SUPD, or statin use in persons with diabetes, is a Part D gap measure, where plans will pay pharmacies to do the work to close that care gap. MTMCMR, hopefully we all know that one, medication therapy management.

is a Part D measure that depends on conducting and documenting comprehensive medication reviews. Care for older adults is a Part C measure that requires a documented medication list review and a functional status assessment. And then, COB, so concurrent opioid and benzodiazepines, and polyACH, which is polypharmacy of anticholinergics, are the newest Part D measures, and they both have a goal to reduce polypharmacy.

Okay. So in this next section, we’ll cover how payer quality programs and performance networks work, why the pay for performance or P4P differs from fee for service, how risk models drive plan incentives, and where pharmacy can bill for services that many pharmacies aren’t as familiar with. So here’s our question to start.

Why are health plans interested in partnering with high-performing pharmacies? Again, please put your answers into our chat. 8.

Pharmacies determine health plan premiums. B, high-performing pharmacies reduce dispensing costs only. C, strong pharmacy performance can help plans improve star ratings and quality outcomes.

And D, regulations require plans to contract only with top-performing pharmacies. Okay, I see some answers in the chat. Thank you for putting those in there.

Those of you who have selected answer. C, you got it. Strong pharmacy performance can help plans improve star ratings and quality outcomes, so they’re going to seek, partnership with those pharmacy groups.

Alright, let’s take a look at the Medicare Part C and D Star Ratings Program. So, we all hear a lot of talk about star ratings, but some of the most consistent feedback that we receive is that pharmacists aren’t fully trained on navigating insurance or quality performance metrics during their curriculums, and this knowledge is usually obtained on the job. So what are the star ratings?

The Medicare Star Rating Program is a quality program that scores Medicare Advantage. MAPD, Medicare Advantage Part D, and PDP Part D plans on the quality of care that they provide. The overall score is an average score of the various measures between the Medicare Part C and Medicare Part D domains.

The Part D domain applies to plans that offer a prescription benefit. And Part C applies to the medical benefit. So, if the plan is a PDP or a Part D plan only, they are only assessed on the Part D domain measures.

The Part D measures are also the measures that are easiest to influence by pharmacy. So if you remember back to our very first slide about the history, where we talked about the Meaningful Measures Initiative, you know that CMS is trying to reduce the burden of excessive measures. So we can see that each year, the total number of points available to be scored has decreased over 3 years.

It went from 85 to 75 to 65. And this is important, because as the total number of points in the measures decrease. The share of the score from Part D has been increasing, which drives plans to invest more into pharmacy performance outcomes.

Of note, MTM was moved to a display measure during the measurement year 2025 and 2026, so we will see the full impact of the changes when it’s moved back to an active measure in 2027. With Part D holding 35% of the total star rating. It’s worth mentioning that, as I said in the previous slide with those HEDIS measures, Pharmacies can impact Part C measures, so we actually do have more reach than just the measures within the domain for Part C and Part D.

And if you look at the total points. that pharmacy can impact. We are actually at 52% of the total star rating score in measures that a pharmacy can directly influence.

Alright, so, we’re gonna break down why this matters for plans. So, the Medicare Advantage star rating tiers and bonus payments are referred to a lot when we’re talking about things like 4- and 5-star plans. So to state it simply, plans that score higher star ratings are going to receive more CMS money.

And so, some important background information that you probably need to understand STARS is to know about the bid. So each year, a plan has to bid CMS for funds, and that’s an estimate of how much money that they’re going to spend to provide care for their patients. The bid is compared to their traditional Medicare fee-for-service benchmark in the county that they’re servicing.

So if a plan bids above the benchmark, they have to charge patients the difference, which increases the cost of the premium. So they do the cost sharing within the premium itself. And if they bid below the benchmark, they get to keep part of the difference, which is referred to as the rebate.

And the rebate dollars that they get back fund supplemental benefits. So a goal you might hear referenced is this thing called a four-star cutoff. So, plans who achieve more than 4 stars are going to receive a 5% quality bonus payment above the local county fee-for-service Medicare benchmark, and in some special counties, they can get up to 10% bonus.

In 2025, quarterly bonus payments totaled $12.7 billion, but only about 40% of plans reached 4 stars. So hitting the 4-star threshold can increase the annual revenue for a plan by up to 18%. And this is the financial, you know, push for why plans want to utilize pharmacies to close care gaps.

So, on this slide, I’ll just give you a quick example about the bid, because I think it’s pretty interesting to talk about. So, let’s say that the benchmark is $1 million in the county that the plan is servicing. A plan that bids below that at, say, $800,000 is going to receive a rebate because they bid below the benchmark.

This plan then works hard to coordinate high-quality care, and they end up scoring 4.5 stars. Because they scored 4.5 stars, this plan would get to keep 70% of that difference, which ends up giving them an extra $140,000. The plan is also going to receive the 5% benchmark bonus, which would be an extra $50,000.

The plan then spends the extra rebate money to provide supplemental benefits, like dental coverage. So you can see on this slide that plans who score higher get to keep a larger percentage of the rebate dollars, and plans that are able to charge lower premiums and offer more benefits, like with the supplemental benefits, are going to be the most desirable to patients and see increased enrollment. When these plans are looking for pharmacy groups to contract with, they will preferentially contract with groups that have a proven track record for high performance.

And these high-performing pharmacies are often part of a performance network. So that takes us to our next slide. We will spend a little bit of time talking about performance networks.

So, performance networks are groups of pharmacies that are rewarded based on their performance. So, one example of a performance network is the Pharmacy Services Administration Organization, or PSAO. or a chain that a pharmacy is associated with.

So payers will look at the performance of that group, and may offer that group preferred network status because they’re high performing. Payers also leverage P4P, or pay for performance models, where they offer bonus dollars that are tied to outcomes. One example of a P4P plan would be a payer who offers end-of-year bonus dollars for achieving higher PDC rates in the adherence measures.

Risk models are interesting. I like, you know, risk models in the bid, they kind of tie in together. They’re interesting because they benefit most from what I consider the invisible impacts of patient care.

So Medicare Advantage plans operate on risk-based capitation, which means that they get more dollars if they service higher risk score patients. And we know that higher risk patients are often the most costly, and improving outcomes for those members is extremely important to control the plan’s costs. So Medicare Advantage plans will leverage high-performing pharmacies to intervene on their high-risk patients because there’s a big reward for that.

And then finally, there are also many opportunities for pharmacies to bill beyond the prescription. So pharmacists can bill using CPT and HCPC codes, and they can document gap closures using coding systems like SNOMED or Low Inc. We have MTM, as previously mentioned, we have RPM, which is the remote patient monitoring programs, point-of-care testing, and diabetes education that are all opportunities for revenue that a lot of pharmacies are leaving on the table today.

All right, so in my next section, we’re going to quickly talk about these services that pay. We’ll talk about the dollars associated with the programs that are out there right now. Hopefully some of you have seen these in practice, and I know we… everyone always wants to talk about the numbers.

Alright, so let’s start here by briefly discussing pharmacy revenue streams that you probably already see in your day-to-day practice, which include medication synchronization, point-of-care services, MTM, gap and care outreach, and immunizations. So MedSync is one of the most commonly utilized pharmacy strategies, because not only does it give you the ability to predict workload and optimize scheduling, but it also drives pharmacy performance and revenue. Beyond the obvious revenue generated by filling a prescription with MedSync, there are also payers who are currently paying pharmacies to just simply call patients and check up on them, like, each quarter.

Some payers are paying pharmacies for the quarterly check-in, and then after that’s complete, each month that the prescription is filled on time, the pharmacy earns an extra bonus for the rest of the year. We’re also seeing payers that will highly incentivize pharmacies to keep patients adherent at the end of the year by time bonuses to the last fill in the year that keeps them within that 80% PDC adherence. Point-of-care services, such as the blood pressure and A1C and test-to-treats, are less commonly implemented, but uptake of these services is growing each year because plans are able and willing to pay for the clinical data that these services provide.

So plans use the data from these interventions to improve quality performance within the STARS Part C domain. MTM and gap in care outreach touch on this part STARS Part D domain. Pharmacies have shown that they can be very successful with closing these gaps, so we’re seeing a lot of these opportunities offered to pharmacies today.

And finally, and I know that we’re all familiar with this one, we’re seeing it right now, Pharmacies have been offering vaccines for many years, and which drives direct revenue via administration fees, but we also see some health plans offering additional incentives when they need to improve their performance on an immunization quality measure. All right, so current program availability, we’ll talk about the programs out there today and how much you can earn from them. The most important thing about the programs that we’re seeing today is that they’re bonus only.

So with the shift away from retroactive DIR fees back in 2024, and towards performance rewards, we’re not seeing the clawbacks anymore for missed opportunities, so if a pharmacy misses something nowadays, the only thing that happens is that they just miss out on that particular bonus. The core component of adherence performance programs is the PDC rate, which we discussed previously, and we know that the goal for PDC is 80%. Payers are incentivizing adherence in two ways, one of which is through pay-for-performance population-level bonuses.

And another, which is by individual patient bonuses at the end of the year. It’s hard to estimate dollars for population-level programs, because each pharmacy services a different number of people, but for the busier pharmacies we’re seeing pay-for-performance bonuses in the hundreds of thousands of dollars, and for very large groups, we’re seeing it in the millions, so this is… Great opportunity. Don’t… don’t forget that these programs are out there.

Keep checking on them. The next program is quarterly check-ins. Which is a fee-for-service opportunity where payers offer a bonus for a short check-in conversation with a patient.

As of today, plans are offering monthly or quarterly check-in bonuses that range anywhere from $5 to $35 per opportunity. Gap closure opportunities, such as making sure that a patient is prescribed a statin or a maintenance inhaler, pay $60 for each validated opportunity. And when I say validation, that means that a claim must be processed after the documentation occurs by the pharmacy.

So if the pharmacy documents that they called the prescriber to initiate a statin prescription, the bonus pays out only after a prescription claim is adjudicated through the insurance after that documentation. Also, to note, there has actually been a small change with gap opportunities very recently, and some of the payers are offering up to $120 for gap closures, related to statins by end of year. So that’s very new.

Last couple of days, actually. And, okay, a new program… this one’s pretty cool. A new program that came to market this year is called On-Time Fill.

That’s the one I briefly mentioned earlier, where after you perform a quarterly check-in for a patient, it just triggers an automatic bonus payment with each refill for the rest of the year. This is… a great program, and I would consider it an easy opportunity for pharmacies, especially those that are using MedSync, because you’re earning extra dollars just for filling a medication on time, assuming you’ve completed the first check-in. And that’s pretty much what we do, right?

We fill the medications. On-time fill bonuses pay $15 for a 28-day supply, or $45 for an 84-day supply. So the HEDIS interventions, such as checking a blood pressure or point-of-care A1C reading, pay anywhere from $35 to $50.

And for this next one called Final Fill, I’m going to spend a bit more time on it because it’s a distinct concept and a high-paying opportunity, and right now is the time of the year when payers are releasing final fills for pharmacies to work on. So, final fill refers to the last fill of the calendar year for a patient that will ensure the patient’s PDC remains above 80%. The final fill of the year is the refill that locks in the adherence status for a patient before the measurement period closes on December 31st.

It’s a one-time bonus of $60, paid once per patient and per year, and because it’s tied to the calendar year, this becomes especially relevant in the fourth quarter, so right now, when you’re making sure your adherent patients stay adherent before the end of the year. And one of the most important requirements about final fill is that documentation of the patient outreach has to occur on or before the day that the refill was processed. So the payers want proof that that final refill of the year was due to the pharmacy’s intervention.

So make sure to be checking these opportunities for dates and catching them before the patient calls in to refill it themselves. I know there’s a lot going on right now with vaccine season, but if you just stay on top of this, and check it weekly, it’s pretty easy money for pharmacies. We have end-of-year adherence bonuses that are also tied to PDC of 80%.

They’re paying out anywhere, anywhere from$30 to$130, depending on the plan. And these are the individual P4P adherence bonuses that I mentioned. And then, again, these dollar amounts do vary by plan, so exposure to these programs is going to vary between pharmacies depending on your patient mix.

But overall, we are seeing a big increase of availability of payable performance programs for pharmacies. I think it’s looking good for us, and with that, I’ll just call it for my section, I’ll wrap it up and pass it to Blair to talk to you about implementing performance programs at your pharmacy.

Blair Thielemeyer, PharmD

All right. Thank you, Roz. Okay, so you know, we’ve talked a lot.

You explained the payer landscape in in such a clear way. I think it’s interesting. Now we’re moving into how does this connect to pharmacy services and more importantly, what does it look like?

to implement one of these successful programs into our pharmacies. So, we’re gonna go through now some best practices for overcoming some of these barriers, once we’ve talked a little bit more about what those are and what those look like for you. And then identifying some strategies for engaging with these Payer Programs, now that you’re familiar with them.

So…  please, Ross. If, if you guys would… would humor us for… for a second. This… there’s no right answer here.

We’d love to hear what is the biggest barrier, because I think, you know, we hear all the time it’s staffing resources, it’s… not sure how to begin. It’s no space to sit down. It’s no time to sit down.

Maybe it’s a technology or an interoperability limitation. So, I’d love to hear some of you guys in the chat. I’m seeing everything.

I’m seeing staff time and workflow. I’m saying not knowing which programs are worth, Pursuing, so hopefully we can… identify some of these challenges and and put in some strategies today to overcome them. So, let’s… let’s start with implementation barriers.

Raza, if you’ll go to the next slide here. We all know, you know, what these are, but there was a formal study done called Flip the Pharmacy, and in this model, what they did is they really tried to understand from, you know, from a community pharmacy perspective, what… what was going on? What were the biggest challenges, challenges that were preventing Pharmacies from really integrating these types of payer programs within their day-to-day workflow.

So you guys have, you know, said it staff time, not enough space, the disconnect that happens during the dispensing process when a staff member, you know, has to step away to complete a clinical service. It may be a technology issue, a claim submission. You know, this is not, kind of the instant adjudication we’re used to.

As Roz pointed out, this is Medicare C and, you know, sometimes D claims. Processed in a different way, we may be using different CPT codes or whatever to clarify what the services that we’re offering. So that’s a huge barrier, not really, you know, understanding how to submit that kind of the back end, the integration pieces that you need for the technology.

The other thing can be a credentialing. That that can be a challenge state by state where you know where pharmacists are not recognized at the federal level. So it may be.

vary depending on the state that you’re in. So as we try to understand what are the complexities around the administrative burden around the staff resources around the, you know, unclear kind of payment models. We’re really trying to you know, help to create some… some workflow best practices for what this actually looks like, you know, in reality, in a day-to-day, you know, sustainable fashion for your pharmacy.

Ros, if you’ll hit the next slide for me here. So there was a few. you know, positive things that… that definitely came out of that flip-to-pharmacy model.

We identified challenges, but after seeing those challenges, there’s also opportunities for us to You know, come up with innovative ideas and innovative ways to still serve our patients at the very highest level. So a few things that were identified was really having that staff team lead or that champion. of the clinical service, designating maybe one or two team members, one pharmacist, one technician, or, you know, whatever that looks like in your store, but really giving ownership of some of these clinical programs.

To staff members and encouraging them to have a, some habits built around that, that is just built into. the KPIs of the pharmacy. So, Roz gave us some of the key performance measures that we know these plans are looking for.

Let’s build our programs in alignment with… with those, opportunities. Education and training. that’s always, you know, something that we need to think about moving forward in the future of pharmacy, how we are supporting our staff members to continue their training and their education.

We’re updating our own, you know, technology, our own policies and procedures. And then putting systems in place, like MedSync, that’s going to help optimize and streamline that workflow within the pharmacy so that more time can be freed up for these revenue-generating clinical service opportunities. So reimbursement’s going to be the key factor for that.

Roz touched on it just a little bit with, you know, some of the different programs that are available. So if you go to the next slide here, Roz, I think Understanding what the different opportunities are, and identifying Which of those programs you want to focus on implementing first? I have a few strategies to share.

We’ll also, I think Kelly will go through how to identify some and do some team training as well. So, Roz, if you’ll… if you’ll go to the next one, some of these strategies for… for payer improvements, how many of you guys are currently Using these programs, doing these programs, and and how are you currently tracking that? What does that look like in your store?

Or… feel free to type something into the chat if there’s some other, you know, way that you’re following. Okay, so I’m seeing some don’t track, mostly is doing with their built-in PMS reports. So there is… Looks like some mix of dedicated performance platforms.

A and B is mostly what we’re seeing. So. I think looking and understanding what you’re going to use, what your system is going to be for continuing to track those numbers that we know we’re looking at, whether you’re using your own dashboard or something that’s provided through a PSAO or a third-party platform.

make sure your staff has access to it. Number one, number one, make sure everybody knows, you know, on the team knows how to log into it, and knows how to get in there, and knows how to find it. So, if you’ll go to the next slide here, Ron.

Those are some, you know, really low hanging fruit for understanding. how, you know, which strategies, which of these, payer programs that you want to engage with, where you want to focus your efforts, understanding what these preferred networks may look like, and I think Raji did a great job of helping us to understand why it’s important for these star ratings measures, and why these scores and performance metrics are something that we need to be paying attention to. So, as you’re, you know, honing in on what that value can be, offering whether that’s a medication synchronization, a delivery service, a rapid pack service, these are the things that you guys are likely already doing in your pharmacy.

It’s getting a better understanding of how you can be billing for these types of services, how reimbursement can be generated as a result of things you’re really already doing, and I think to go back to Roz’s point, it’s the documentation piece of it that figuring out how how we can be recognized and tied to, you know, an on-time fill, for example. How can… how we have to go in there and document the intervention that the pharmacy made. in order to, you know, be able to capture these opportunities.

So that’s number one thing, I think, strategy for being able to really put your pharmacy in a great place to engage with some of these Payer programs. Okay, next… next slide here, too. The performance network status, again, I think you guys have, kind of… Razi kind of went through it.

With the preferred status, the way that this works with what we’re seeing, creating kind of this flywheel effect of pharmacies that are engaging with these programs, they are going to see even more volume being delivered as part of these programs, as we can, you know, help Medicare programs to achieve higher and higher star ratings. that, you know, connects to the contracts and things that we can put in place moving forward. So it’s really exciting to see pharmacy being recognized, you know, in that timeline of changes that has happened through the value-based care performance landscape throughout the past you know, 10, 15 years, it’s really exciting to see pharmacy becoming more and more , you know, in engaged with in these, in these payer plans.

too. Again, this stronger network, like, this is… this is what we’re… we’re here for, and I know Kelly you and everyone at IPC, you know, are helping to bring pharmacies to educate them around what these opportunities are, and how These… these opportunities are leading to more and more opportunities for the Pharmacies to engage in clinical services. It’s really a factor of being able to document and being able to tie These interventions, our interventions and the services we’re already providing to our patients to outcomes for these payer networks.

And then, okay, so how you get paid. I think this goes back to the very beginning with the PDC percentage rate. So, as we’re looking at these scores, the question was around What metrics are you using?

How are you tracking these things? So if you’re looking at PDC scores, that is something that’s tracked over the 365 days of the calendar year. So, as Roz mentioned in the beginning, we have a start date from your first fill, looking at.

where the patient is at, whether you’re filling… you’re pulling these reports from your pharmacy management system or some other dashboard. This is… this is what’s going to help you create a, a really solid MedSync program, delivery. All the different types of services that you can offer.

this is probably the, I will say, the lowest hanging fruit, the KPI, that if you’re not watching this, if there’s one thing you kind of walk away from this program with, it is Understand PDC adherence rates and understand how those are being impacted by your daily dispensing workflow and the processes that you’re already doing in your pharmacy. Okay.  please.

And with that, I will move it to Kelly. Thank you.

Kelli Stovall

Thank you, Blair.  Rosalyn. First, let’s start with a question.

So which strategy is recommended to help pharmacies successfully participate in performance-based programs? Take a look and read your choices, A, B, C, or D, and put it in the chat. Is it review performance data annually?

Wait for payers to identify opportunities? Designated performance program champion or focus exclusively on dispensing efficiency. Hey, Rosalyn, looks like… Everyone’s getting the right answer in the chat, which is fantastic.

Correct answer is C, designate a performance champion. Let’s see, let’s go to the next slide. So we’ve had great information so far.

Rosalyn has given us great descriptions of these programs and what they mean for our stores. Blair referenced Adherence Champion, and that’s where I’m really gonna hone in. I’d like for us now to kind of take… get in the weeds and take a look at how we can Choose that champion, and how we can implement that into our business, really, to make all of this come together, where we’re improving adherence, and we are earning revenue on these financial opportunities.

So obviously, as Blair referenced, it is highly recommended to assign an adherence program champion for a successful program. And we want to choose the right person. And here’s where a lot of programs can fail.

Everyone can agree that something’s important, but if no one is actually responsible for it making it happen, then it doesn’t happen. Adherence is no different. So, if you have plan… if your plan is to have everyone work on adherence whenever they have time.

There’s really not a plan. So you need that one person who owns the process. That person doesn’t necessarily need to be your pharmacist.

A good pharmacy technician who is organized, dependable, communicates well with patients, and follows through can be your excellent adherence champion. Your pharmacist will still handle those clinical decisions. But your champion manages the day-to-day process.

And I would… I would say, don’t automatically choose the most experienced employee. Choose the person who is motivated, to take ownership in this process. And remember, I’ll kind of repeat this here, is if everyone’s responsible for adherence, there’s a really good chance that nobody is taking accountability for it.

So let’s look at the next slide. So adherence as a revenue opportunity has some great examples from Rosalyn and Blair. And so I won’t I won’t repeat those, but I want to remind you that your financial opportunity depends on your contracts, your performance, and whether the incentives justify the work required.

But you should at least know where the opportunities are, and you should have someone paying attention to it. Because here’s the reality if you have Payer performance opportunities available. And nobody in your pharmacy is actively managing them, then you’re leaving those opportunities to chance and you’re leaving dollars on the table that you could be collecting.

All right, let’s look at that  and this is where we’re really going to get into some things here. You know, I would say, don’t make the mistake of giving your champion or someone a new responsibility without giving them the tools to succeed. Some of those tools have already been mentioned.

Training is a big one. Obviously, they need training. The one thing I would like to point out, that they need dedicated time.

And it doesn’t mean necessarily hiring another employee, but they need that dedicated time. And you can start with 20 or 30 minutes a day, and that time has to be intentional. Your champion needs to know what they’re supposed to accomplish, how they’re going to measure it, how many patients need attention, what patients are at risk.

But here’s the bottom line. You can’t hold them accountable for results if you haven’t given them the ability to do the job, and a lot of times that comes down to that intentional, dedicated time. And I would say when adherence matters, we know it matters.

We just have to treat like it matters. So you want to build a simple daily workflow. Your champion doesn’t need an elaborate workflow.

They just need a process they can repeat consistently. They should review the dashboard, identify priority patients, follow up on medication gaps, document their work, and make sure unresolved issues don’t get forgotten. That’s it.

You want to build the workflow around completing the invention intervention, not just checking a box. Use the dashboard for your action plan. You know, I see a lot of pharmacies that have access to excellent performance data and a lot of financial opportunities out there, but they aren’t doing much with it.

And let’s talk about measurement. That was mentioned earlier, too, but that champion scorecard is incredibly important, because if you’re paying someone to work on adherence performance, you need to know whether the investment’s producing those results. Your champion should have a simple scorecard, doesn’t need to be complicated or time-consuming, but you need to look at those numbers with your champion.

Each week. Something isn’t working, then you have that opportunity to change it. Understand that adherence performance doesn’t improve overnight.

Obviously, PDC is cumulative, and some won’t change immediately. But you should be able to see whether the process is being executed, and whether the underlying indicators are moving in the right direction. If you aren’t measuring the results, you don’t know whether you have a performance program or just another task keeping your staff busy.

Quickly, I want to look at just the Champion’s first 30 days to help you think about really how you can implement this. It doesn’t have to… it does not have to be complicated. You can really get this basic process established in 30 days.

Week one, identify your champion, get them trained, make sure they understand the measures, know how to use your performance platform, make sure they’re trained and can navigate that dashboard, and understand those payer programs. What are the specifics in the Humana one? What are the specifics in Centene?

Do you know what these measurements mean? And establish where your pharmacy stands today. Week two, start working the patient opportunities.

The champion can make the calls, resolve the progress. problems, and of course, document the work. Week three, you want to refine the workflow.

Now take a look at your first two weeks. What do you need? What’s taking too much time?

Where are patients getting stuck? Are prescription renewals slowing things down? Would MedSync or delivery help?

Are there different ways to manage that? And week four, review your results. What was accomplished?

What’s still open? What needs to change? Then establish a weekly review with your champion.

Ten or fifteen minutes a week is all you need. You know, and I want to close with this. For years, independent pharmacies have been told they need to move beyond relying entirely on dispensing revenue, and that’s true.

And you already have access to performance data. You already have contracts that offer financial incentives. So what’s missing is often that consistent process and someone who’s accountable for making it work.

Because here’s the reality. If you have Payer performance opportunities available. And nobody in your pharmacy is actively managing them.

You’re leaving those opportunities to chance, and chance is not a business strategy. Remember, you don’t improve what nobody owns. Assign the responsibility, build the workflow, measure the results, and know what it’s worth to your pharmacy.

That completes our program. We would like to take a few minutes to address any questions that have come through. And after Q&A, we will display the instructions and code to claim the CE.

This program will also be available on demand within the next few weeks, so please share with staff and peers. So now let’s see if we’ve got any questions that have come through. And we do have one.

From what you are seeing, how significant is the opportunity for independent pharmacies that make working these a priority, both from a performance and financial standpoint? I’ll… I’ll address the financial standpoint. You know, we’ve… we’ve had a fantastic opportunity to work with these two ladies on… on… on screen, but also our members on… on their financial opportunities and Payer Performance Programs.

And we have seen big dollars out there. $30,000, $40,000, $50,000 a year. I mean, these aren’t small.

Some stores with a lot of patients from that payer can make substantial dollars in this, and so it, you know, it is worth the time for that, and the process that you go to set up this. Blair Rosalyn, would you like to add anything to that question?

Blair Thielemeyer, PharmD

Yeah, I think so. Part of the question is, you know, where can they find answers to some of these questions? Where they?

Where can they find trainings? And so I think we have. We have a lot of that knowledge, you know, put together if if she wants to reach out.

But I I think, you know, in general. understanding how to get into these platforms, where to look, you know, that’s the number one thing. if… depending on which state you’re in, I think that’s also a question around some of the point-of-care service.

That… that she’s asking is… what opportunities are you having to bill in your state? So it may be a, you know, a combination of reaching out to, you know, myself or Rosalyn, reaching out to Kelly and some of the people. We’re really here to help, to point you in the right directions, and there’s A lot of staff training and education things.

that, that are available for, you know, for pharmacies that are ready to start implementing these services. So we wanna be here to help.

Kelli Stovall

And I’ll go ahead and read that question. That was our second question that came through from, and it says, my question is to Rosalyn Blair. I know you addressed this as well.

If we need help with clinical opportunities like point of care services. A1C, blood pressure, lipid, et cetera. Who do we approach?

What’s the platform we can find answers to these questions, especially how to build Part C services? Would you like to respond to that, Rosalynn, as well?

Rosalyn Otting

Yeah, so we’re doing our best not to, introduce commercial bias into this CE, so I’m probably just not gonna name them by name, but I can tell you that there are built-in programs within your pharmacy management software. There are systems that are separate, there are systems that float on top. They are out there, and if you want like, connections with them, feel free to reach out to Kelly, feel free to reach out to me or Blair afterwards, but they are out there on the market, and they are surfacing these opportunities every day.

And also, back to that first question, how significant is it? I will tell you, I have seen pharmacies miss on $80,000 by one non-adherent patient. It is so rough to see that.

And I work with pharmacies who, like, they say, we had no program in place, we weren’t even looking at our numbers. The next year, they bonused $120,000. Of course, they’re, like, slightly busier pharmacy.

They are an independent, and it as I mentioned earlier, depends on your patient and your payer mix. But we have payers putting out programs for specific locations. Like Michigan, Texas, we’re seeing things in California, Florida, specific states, so you could get a regional program specific to you.

We are also seeing that payers are looking at the pharmacies that are, engaging with these programs, and they’re incentivized, they’re offering more opportunities to them. They’re saying, okay, I know this MPI. is doing the documentations.

They’re addressing my gaps. I’m going to offer them another $2,000 of bonuses, because I know they’re going to work on it, and they’re going to help me improve my scores. They’re also… some of these payers are… paying for software for the pharmacies to be able to float opportunities into their dispensing workflow, so that the pharmacies don’t have to pay for extra software.

They’re, like, sponsoring it, so… Lots of opportunities, but the baseline is you just have to get engaged, and if we want to push pharmacy forward in this realm, we just have to… everybody has to kind of get on board.

Kelli Stovall

We do have another question that came through. Where does a newly startup pharmacy fit into all of this? I’m a few weeks in, not sure what I can do to move the needles most.

Blair Rosalyn, do you want to respond to that?

Blair Thielemeyer, PharmD

I think… so, I think this is a great place to be in, you know, building fresh and starting fresh, so you have the opportunity to create and build a program that aligns with, I think, some of what we’ve talked about as far as these opportunities, but also getting an understanding of, you know, what the opportunities for your scope of practice in your state looks like. I think, what can you do to move the needle the most? I think really looking at those services, like a medication synchronization program from the very beginning, it would be a good move to help you know, help your pharmacy grow and help to establish some some real systems and processes that can help you be successful.

So best of luck.

Kelli Stovall

And I would add to that as well, log into that, your dashboard, take a look. If you’ve got patients and you’re accepting, you know, if you’re accepting insurance, med D, anything like that, it’s, there’s a good possibility that you have some patients there that you may have some financial opportunity with.

Rosalyn Otting

Yeah, another thing Pharmacies that will do, they’ll understand their payer mix. They’ll log into the individual patient profiles that have that insurance and just put a note, be like, “Hey, this patient is from Plan A. Keep them in mind when their prescriptions pop through your queue.” Put a bag tag on them, something like that.

Don’t let their prescription get returned to stock when it’s an adherence refill.

Kelli Stovall

Okay, I think that that’s our time. We’ve got just a few minutes. Let’s put our instructions for claiming the CE on the screen, and we’ll leave that up for 10 minutes or so, 10 to 15 minutes, so everyone can make sure that happens.

It is… it is sponsored through CE Impact, so… and I think Joe or Sam shared our contact information in the Q&A, so feel free to reach out to us, and we really appreciate your time today, and we’re so glad you joined us.

Rosalyn Otting

Thank you, everyone.

Kelli Stovall

Thank you.