Empowering Pharmacies to Add New Sustainable Care Services

With 90% of Americans living within 5 miles of at least 1 pharmacy, pharmacists continue to see a surge in demand for services.¹ In fact, patients visit their community pharmacist roughly twice as frequently as they visit primary care physicians, with Americans living in rural areas even more likely to visit their local pharmacy. Convenient access to pharmacies is particularly important because nearly half of US counties already face shortages of primary care providers, with just 1 physician for every 1500 people.²

PRTM is an interactive visualization tool that provides pharmacies with billing code–level insights | Image credit: improvee design | stock.adobe.com

The shortage of primary care physicians in the US is projected to worsen. The American Association of Medical Colleges expects that by 2032, there will be a shortage of up to 122,000 physicians, including up to 55,000 in primary care and 66,000 in other specialties.³ Filling these health care gaps with pharmacists, who are already embedded in the community as trusted sources of reliable quality care,⁴ is both necessary and urgent to ensure people have access to the services they need.

The recent Wolters Kluwer study Pharmacy Next: Consumer Care and Cost Trends Care Expands Beyond the Clinic concluded⁵:

“Americans are increasingly seeking care outside of the traditional doctor’s office due to a growing trust in providers in non-primary care settings for certain medical needs…Care is rapidly decentralizing and with younger generations leading the way, healthcare stakeholders need to be prepared for a fundamental—and permanent—shift in care delivery. 81% of Americans trust a pharmacist, nurse, or nurse practitioner to provide care when they or a family member are sick.”

The Pharmacy Next study only reinforces the essential role that our local heroes, the neighborhood pharmacists, have played. Americans have increasingly turned toward pharmacists for point-of-care testing for flu, strep throat, and COVID-19; for chronic condition management for diseases such as diabetes; and for smoking cessation and medication therapy management.

Expansion of testing and treatment options is leading pharmacists to increasingly establish the infrastructure necessary for services and seek support for navigating billing processes for patients and payors. However, pharmacists looking to remain competitive in a margin-compressed environment need accurate and timely data, such as contracted reimbursement rates.

Pharmacists, supported by some payors who have been embracing a “provider-like” role, want to use their many years of education and training alongside physicians to do more for patients beyond occasional advice and filling prescriptions. But pharmacists struggle to understand what kind of reimbursement may be available to them from payors and what services may be sustainable. A new Payor Rate Transparency Monitor (PRTM) from XiFin offers a solution to help better manage the business side of pharmacy.⁶

Introduced at the National Association of Chain Drug Stores – Total Store Expo in August 2024,⁷ the PRTM is an interactive visualization tool that provides pharmacies with billing code–level insights into contracted payor reimbursement rates. It delivers critical comparative data that enables pharmacies to make informed financial decisions and support patient testing needs.

It arms pharmacists with contracted rate information to support their negotiations with payors and to compare their reimbursement against their contracted rates. The PRTM allows pharmacies to select their medical billing category, billing codes, and billing modifiers across 1 or multiple payors to better understand and inform their market access and payor relations strategies.

The PRTM is made possible by the Health Plan Transparency in Coverage (TIC) Final Rule on July 1, 2022, enacted by the Centers for Medicare & Medicaid Services. TIC requires most group health plans and individual health insurance coverage to disclose personalized pricing information for 500 commonly covered items and services to their participants, beneficiaries, and enrollees through an online consumer tool, by phone, or in paper form, upon request. However, TIC’s transparency has had unforeseen benefits that go beyond consumer empowerment.⁸

Data from TIC now enable pharmacies to see the contracted rates for the first time. Diving into TIC data, pharmacists can now compare their contracted reimbursement rates to other providers within and across payors, delivering clear insights into how their rates compare and informing their payor contract negotiations.

Drawing from the petabytes of data reported by payors pursuant to TIC, the PRTM assimilates and analyzes data, pulling out actionable insights in an easy-to-follow graphic interface. It provides information on a number of commonly submitted current procedural terminology codes.

For each billing code and billing modifier combination found in the payor files, the PRTM summarizes the total number of distinct rates and the high, low, and weighted averages by payor. The monitor then visually indicates the distribution of rates and the relative volume of providers having the same agreed-upon rate. Hovering over a bubble in the chart shows the rate and the count of how many National Provider Identifiers are associated with that rate.

The PRTM is continually being refined and expanded. It currently features in-network rates for 4 of the nation’s largest payors: UnitedHealthcare, Cigna, Aetna, and Blue Shield of California. With data updated on a monthly basis, the pharmacy-specific monitor showcases billing codes selected for their relevance to pharmacies, even as they expand their medical service offerings.⁶

Pharmacies need to know that the services they are offering are sustainable and reimbursable while serving the needs of the patient community that may otherwise fall into the care gap widened by the physician shortage. This critical comparative tool empowers pharmacy teams to proactively engage payors to advance market access and payor contracting discussions, ultimately championing greater access and equity for patients in communities across the country.

Having access to tools like the PRTM will enable pharmacists to build healthy businesses with greater efficiency and, in so doing, enable pharmacists to continue being key health care providers while filling care gaps and enabling better access for all.

REFERENCES

1. Pharmacist Shortage While Most Live Close to Pharmacy In US. HCC Pharmacy Staffing. July 31, 2024. Accessed March 12, 2025. https://pharmacy-staffing.com/blog/pharmacist-shortage-while-most-live-close-to-pharmacy-in-us

2. Pope D. Protecting Patient Access to Pharmacies. Drug Store News. November 21, 2024. Accessed March 12, 2025. https://drugstorenews.com/protecting-patient-access-pharmacies

3. New Findings Confirm Predictions on Physician Shortage. News release. Association of American Medical Colleges. April 23, 2019. Accessed March 12, 2025. https://www.aamc.org/news/press-releases/new-findings-confirm-predictions-physician-shortage

4. Honesty/Ethics in Professions. Gallup. Accessed March 12, 2025. https://news.gallup.com/poll/1654/honesty-ethics-professions.aspx

5. Pharmacy Next: Consumer medication worries amid pharmacy closures. Wolters Kluwer. Accessed March 12, 2025. https://www.wolterskluwer.com/en/know/pharmacy-next

6. Payor Rate Transparency Monitor. XiFin. Updated February 19, 2025. Accessed March 12, 2025. https://pharmacy.xifin.com/resources/payor-rate-transparency-monitor/

7. OmniSYS Becomes XiFin Pharmacy Solutions, Launches Pharmacy Payor Rate Transparency Monitor and Receives Industry Recognition with Pharmacy 500 Award. News release. XiFin. August 15, 2024. Accessed March 12, 2025. https://www.xifin.com/news-and-events/press-release/omnisys-becomes-xifin-pharmacy-solutions/