Pharmacists Can Leverage Future Roles in Outcomes-Based Payment Models

The US health care system continues to evolve further in value-centric modalities of recognition and reimbursement, prompting the adoption of performance-, value-, or outcomes-based payment models (OBPMs) aimed at improving patient outcomes while reducing costs. Although originally targeted at physicians and health care systems, OBPMs are increasingly prevalent in community pharmacies. However, challenges persist in their design and implementation, necessitating a deeper understanding of their structure, operation, and contextual factors for successful integration. Additionally, reimbursement constraints imposed by pharmacy benefit managers (PBMs) have exacerbated financial strains on community pharmacies, leading to closures and inefficiencies in patient care.

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OBPMs vary in implementation across pharmacy settings and entities, catering to diverse populations including Medicare, Medicaid, and commercial beneficiaries. Core components include attribution, performance and quality measures, incentive structures, and patient care services.¹ The Merit-Based Incentive Payment System (MIPS) measures providers on several categories of quality, resource use, clinical practice improvement activities, and advancing care information. The Centers for Medicare and Medicaid Services (CMS) uses a positive, negative, or neutral payment adjustment to each MIPS-eligible clinician and physicians can earn bonuses if they achieve higher scores through MIPS measures,¹ preserving a version of the fee-for-service model while also focusing on efficiency and quality.

Limited research exists on how pharmacists influence MIPS and related patient-centered medical home (PCMH) quality measures. A recent study assessed the financial viability of pharmacists providing Medicare annual wellness visits (AWVs).² Collaborating with physicians to deliver AWVs could help better actuate pharmacists’ roles in physician offices. Despite OBPMs’ potential benefits, challenges such as measure alignment, attribution complexity, and conflicting stakeholder interests hinder effective implementation. Recommendations emphasize transparency, alignment of measures/benchmarks, an organizational culture of quality, and operational infrastructure needs.²

Current attribution models commonly allocate patients retrospectively based on prescription volume, yet there is potential for enhancement by attributing patients at the point of care. Pinpointing the exact contribution of a single provider is complex, as both pharmacists and other health care providers may influence patient adherence and other metrics. Metrics integrated into OBPMs exhibit diversity across services, payers, and contractual agreements. Participants noted that these measures predominantly evaluate health care processes or intermediate outcomes such as medication adherence.³ Many of these metrics were originally designed for other health care professions, such as the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) measures for medical providers, and various payment settings, such as Part D star ratings. Patient care services represent a vital component of OBPMs, focusing on delivering services aimed at enhancing patient outcomes. These services include comprehensive medication reviews, medication therapy management, medication synchronization, and immunizations. While participants generally observed positive impacts on patient care from these services, payers exhibited reluctance to reimburse for them independently of OBPMs.³

Lack of transparency and communication among stakeholders further complicates the payment system, leading to inefficiencies and gaps in patient care. Legislative efforts to expand pharmacists' scope of practice and enable billing for clinical services have been hindered by inadequate reimbursement mechanisms. These challenges underscore the urgent need for reforming the reimbursement structure to ensure sustainability and promote high-quality patient care.

To address reimbursement challenges and enhance OBPMs in community pharmacies, 4 alternative payment models were proposed by Mercadante et al:⁴

1. Pharmacist Attached to Primary Care Physician (PCP) Offices: Integrating pharmacists within PCP offices to complete medication management services
2. Transparency Payment Model: Providing patients with upfront medication pricing to help in payment choices
3. Accountable Care Organization (ACO) Plus Patient Model (ACOPP): Involving patients in ACOs to distribute risks and benefits among health care providers, pharmacists, and patients.
4. Pharmacist Network: Creating a network of pharmacists offering clinical services directly to patients with a focus on medication non-adherence and enhancing care accessibility

Enhancing OBPMs and addressing reimbursement challenges in US community pharmacies requires a multifaceted approach. Transparency, alignment, and a culture of quality are essential for successful OBPM integration, while innovative payment models offer opportunities to mitigate reimbursement challenges and promote sustainable pharmacy practice. Through newer and evolving models of quality-based performance paradigms, health care providers feel the pressure to practice accordingly.

By integrating pharmacists more thoughtfully and comprehensively into the delivery of direct patient care services, we can make a positive impact on measures evaluating quality in different types of practice networks. The pharmacist integration model filled in gaps in care that appeared to positively affect MIPS and PCMH quality measures.² This has the potential to increase reimbursement through value-based payment models.

Further research and implementation efforts are needed to evaluate the effectiveness of these models and address the challenges facing community pharmacies in the US health care landscape. Ultimately, proactive strategies and inclusive approaches are essential for advancing value-based care delivery and ensuring the sustainability of community pharmacy practice.

References

1. Richard C, Urick BY, Pathak S, Jackson J, Livet M. Performance-based pharmacy payment models: key components and critical implementation considerations for successful uptake and integration. J Manag Care Spec Pharm. 2021;27(11):1568-1578. doi:10.18553/jmcp.2021.27.11.1568

2. Sinclair J, Bentley OS, Abubakar A, Rhodes LA, Marciniak MW. Impact of a pharmacist in improving quality measures that affect payments to physicians. J Am Pharm Assoc (2003). 2019;59(4S):S85-S90. doi:10.1016/j.japh.2019.03.013

3. Urick BY, Pathak S, Cook SD, et al. Relative contribution of pharmacists and primary care providers to shared quality measures. Explor Res Clin Soc Pharm. 2022;7:100165. doi:10.1016/j.rcsop.2022.100165

4. Mercadante AR, Yokota M, Hwang A, Hata M, Law AV. Choosing Evolution over Extinction: Integrating Direct Patient Care Services and Value-Based Payment Models into the Community-Based Pharmacy Setting. Pharmacy. 2020; 8(3):128. doi:10.3390/pharmacy8030128