For the decades, neighborhood pharmaceutists have been asking for different models of payment for clinical services, mainly as the training they get has shifted towards a focus on patient care, and in-depth clinical decision-making. These immediately available health care specialists have the potential to play a significant role in the ability of the sufferers they see every month. However, the widespread change from a focus on giving has yet to occur.
The fundamental and time-intensive nature of dispensing a high volume of medicines every day takes too much of the pharmacist’s time, yet medicine volume continues the primary revenue driver. Further, even if pharmacists had the time, their access to use reliable data is minimal, making it hard to know which sufferers to focus on or how to best care for them.
Subsequently, and most critically, payers and health systems have been traditionally reluctant to pay pharmacologists enough to make it a sound marketing decision for them to spend a meaningful amount of time caring for patients.
The Efficiency Of Managing Activities
Overall, payer uncertainty issues unrelated to the need for proof of pharmacologists’ value in maintaining the chronic disease. This body of testimony has grown so large it is hard to refute. The main drawback is scalability—if payments for outpatient care services were performed at scale, would pharmacologists across the country collectively have the ability to change their day-to-day workflow, spend time with sufferers, and manage treatment for populations the way they are trained?
While it would be a disruptive change in the United States’ primary care delivery model, there exists great potential for pharmacologists to mitigate the burden of chronic disease—the most critical driver of morbidity, mortality, and cost in US health care (~96-99% of Medicare spending).
In recent years, there has been significant progress in increasing the efficiency of managing activities through automation, apparently giving druggists more time to produce clinical projects. The appointment-based model has increased traction as a way for drugstores to transition their care means to a more proactive passageway.
There have also been significant grassroots applications, such as the Community Pharmacy Enhanced Services Network (CPESN), to improve the level of service required from a community drugstore, particularly for independents and small chains. With these advancements, in a time where many medicines are seriously in search of new revenue channels, due to contracting dispensing margins, perhaps pharmacies are willing to accept the risk of assuming a new care model in their applications.
A Pharmacy-Friendly Payment
The development of a distinct Medicare Advantage plan, Troy Medicare, offers much-needed momentum to drive pharmacologists’ services. Troy’s model puts pharmacologists in the driver’s seat of chronic care, namely by introducing per-member-per-month fees of $30-$50 to drugstores that fill directions and provide medical services for their members.
Troy will also offer technology that allows pharmacologists to have a clear view of patients’ healthcare history, as well as the interoperable transfer of pharmacy care plans (eCare Plan) between healthcare settings.
Through these clarifications and a pharmacy-friendly payment model that uses NADAC (Methodology for Calculating the National Average Drug Acquisition Cost) pricing, imposes no DIR payments, and provides flat dispensing fees, Troy hopes to increase transparency and support pharmacies as a business. More broadly, this model views of leveraging pharmacologists’ expertise as chronic care managers to improve seniors’ issues and lower total price of care.
As a head of its kind, Troy Medicare has developed at a suitable time, offering financial versatility that pharmacologists and drugstores have been seeking. Service-based revenue will enable more drugstores to invest in the required technology and become much more advanced in care delivery.
Pharmacists’ ability to regularly and meaningfully engage with patients to improve their care is not only more gratifying for pharmacologists, and it is a lower-cost option for high-quality chronic illness administration.
Nonoptimized vaccinations are an immense driver of avoidable cost in US health care (>$500 billion/year), and the pharmacist’s training, knowledge, and skill are precisely oriented to the management of complex medication regimens for patients with chronic illness, more so than any other health care specialist, including physicians. Perhaps we are approaching the pharmacy’s perfect storm—a confluence of factors that will catalyze societal change in the way chronic medication administration is delivered.
All In All
As outcomes-based down and quality measures continue to influence provider reimbursement strongly, community drugstores positioned as integral members of the health care team will become essential. Troy’s model produces an ideal environment for this transition to reach critical mass.
By merely promoting a model in which pharmacologists can focus less on filling prescriptions, and more on filling their intended role, payment models like Troy’s could be the force needed to pull the linchpin in pharmacy’s long-awaited division.