Value-Based Payment Programs in Healthcare and Their Application to Pharmacies
Pharmacies and pharmacists have expanded their clinical roles beyond medication dispensing and adherence, to include medication adjustment, vaccination, and outcomes monitoring. Value-based payment (VBP) in pharmacy has the potential to recognize these contributions that improve patient outcomes and affordability.
Over the last decade, VBP programs have evolved to pay providers based on the quality and value of the care they provide rather than solely based on the volume of services delivered. Pharmacists, with their expanded scope of services and clinical expertise, can contribute to and be recognized for improved patient outcomes via participation in VBP programs. However, pharmacy VBP is less established and can benefit from learnings from other VBP programs in healthcare.
In general, VBP models that have demonstrated greater success to date include those with mandatory participation, longer contracting periods, risk-sharing on the part of the provider or organization, and technical and professional support for providers. Further, pharmacy program metrics should be standardized and built on current reporting programs, particularly with respect to clinical management of patients.
Related Public Policy Research
Data show that states that employ managed care organizations (MCOs) to manage the Medicaid prescription drug benefit collectively exhibit higher scores on pharmacy-related clinical quality measures than states that rely on the fee-for-service (FFS) setting to administer the benefit.
PBM and Community Pharmacy Partnerships Can Improve Medicaid Outcomes
Individuals’ visits to community pharmacies outnumber visits to other healthcare provider types by nearly 2:1. Value-based care arrangements between pharmacy benefit managers (PBMs) and independent community pharmacies, where enhanced services are performed, can improve outcomes for individuals at higher risk for poor health outcomes.
PBMs are companies that administer the prescription drug benefit for health plans and employers. PBMs add value in three primary ways: improving health outcomes using evidence-based clinical programs, effectively managing pharmacy networks, and using financial management strategies to reduce prescription drug spending and costs.