For a variety of reasons, including controversial direct and indirect remuneration (DIR), pharmacies and pharmacy benefit managers (PBMs) are not the friendliest partners. There are growing fears that Pharmacy Benefit Managers (PBM) Business Practices inconsistent with public policy objectives to add value to pharmaceuticals expenseswhile organizations such as the National Community Pharmacists Association (NCPA), main push to close legislative loopholes that hurt small pharmacies but benefit PBM.
However, against the backdrop of noisy legislative battles and drama, the need for closer cooperation between pharmacies and PBM is becoming quite clear.
CMS has taken decisive action to increase the incentive to provide value-based care. The agency doubled its weight in 2020 CAHPS Health plan survey metrics related to member experience, which now account for almost 40% of the health plan’s overall star rating, three times more than just a few years ago. At the same time, metrics related to blood pressure control, all-cause readmission planning, and transition to treatment returned to stellar ratings.
Given that participants’ experiences with their pharmacists affect the perception and star rating of health insurance plans, a collaborative relationship between care partners can use a little therapy for couples.
Why It’s Important to Improve the Relationship Between the Pharmacy and the Health Plan
While the concept of “Member Experience” is somewhat vague and CAHPS scores do not always reflect the quality of care, health insurance plans are under tremendous pressure to perform well and deliver 5-star care and service. For some plans, anything less than 4.5 stars could hurt the payer’s ability to keep going given the wider surge treatment of chronic diseases and readmission costs.
But what we do know for sure is that participants’ experience—and what participants report on CAHPS surveys—depends on their relationship with all educators, not just doctors.
Pharmacy professionals are increasingly working to the limit of their licenses. They are more likely to vaccinate and offer advice and counseling to patients than at any time in history. In underserved parts of the country sometimes mentioned as “physicians of the desert,” Americans may interact more often with their pharmacy professionals than with their regular physicians.
Bottom line: If patients receive exceptional care at their pharmacy, it will ultimately benefit the health plan. If pharmacies cut staff or service to make up for PBM returns, those cuts affect service. And if the quality of service declines, so does the perception of participants.
Let’s say a diabetic patient doesn’t get their medication in a timely manner because they struggle to get it, his or her outcome may worsen as well as their perception of their experience.
Let’s get together
The health care plan and collaboration-based partnerships with pharmacies are better prepared for success.
With that in mind, here are three ways health plans can work more closely with pharmacies to enhance the member experience and their star ratings:
1. Make sure community pharmacies have agreements based on visible values.
Pharmacies are not always aware of the internal policies or pricing decisions made by health insurance plans, such as the amount of money they will have to pay for dispensing certain drugs.
But having very visible value-based agreements and programs with pharmacy chains can do wonders for improving communication in all areas (including discussion of initiatives to support high impact quality measurement improvements).
An American Journal of Managed Care interview Joseph A. Albright, pharmacist, clinical pharmacy program manager at Blue Cross Blue Shield in North Carolina, highlighted the momentum as plans enter into collaborative arrangements with health systems. “Often when you first start out, there is a hostile relationship when it comes to the payer and the supplier, because we are used to butting foreheads,” Albright said. However, Albright also said that his best relationships with doctors are those in which they are explicitly involved in decision making and are treated as equal partners. Similarly, value-based programs through direct agreements with pharmacy chains can drive collaboration and efficiency.
2. Use an integrated care management platform to better coordinate care and value-based initiatives.
When health plans, PBMs, and community pharmacies use different technologies to track supply chain management, medications, and patient care, it can be difficult to track performance-related progress (e.g., adherence, flu shots, drug plan satisfaction) and engage participants in an agreed manner. Using an integrated clinical care management platform can help optimize drug use, monitor care management, reduce avoidable healthcare costs, and improve reporting for compliance and quality metrics.
3. Look for the Easiest Reciprocal Star Rating Opportunities
Health plans regularly analyze data sources such as CAHPS data and their own prescription data to find the most obvious opportunities for improvement. But they don’t always communicate their findings through these deep reflection exercises to their care partners. This is a mistake because there are many great opportunities for pharmacies to work with health plans to improve care and service. Once value-based intervention mechanisms are in place and run through integrated clinical platforms as discussed above, the platform exists for a very prominent focus on mutual opportunities to improve specific pharmacies.
No guessing, pharmacists can do what they do best – solve problems. For example, if Part D adherence rates are lower than expected, pharmacy partners may have simple “fixes” in mind, such as rolling out a new web chat or automated refill service, that can help patients get their medications on time. as well as easier to help with this “Getting the Recipes Needed” measure!
Working together to achieve common goals will become more important for all health stakeholders as values-based care spreads throughout the country.
When health plans and pharmacies enter into a collaborative rather than competitive relationship, both are more likely to succeed in the CMS Star ratings program and other quality initiatives, and this success results in more members who are satisfied with their service and stay in their plan. . .
Anna Hall, PharmD, BCACP is the director of quality control in Transactional data systemspharmaceutical technology and analytics company.