For a variety of reasons, including controversial direct and indirect remuneration (DIR) clawbacks, pharmacies and health plan pharmacy benefit managers (PBM) aren’t the friendliest of bedfellows. Concerns are growing that pharmacy benefit managers's (PBMs) business practices don’t align with public policy goals to improve the value of pharmaceutical spending, while organizations such as The National Community Pharmacists Association (NCPA) are making a major push to close legislative loopholes that hurt small community pharmacies but benefit PBMs.
Yet amid the noisy legislative strife and drama, the need for stronger collaboration between pharmacies and PBMs is becoming abundantly clear.
CMS has taken decisive action to strengthen the impetus around value-based care. The agency in 2020 doubled the weight CAHPS health plan survey metrics pertaining to member experience that now account for nearly 40% of a health plan’s overall Star rating — a threefold increase over just a few years ago. Simultaneously, metrics related to controlling blood pressure, plan all-cause readmission, and transitions of care have returned to the Star Ratings.
Given that the experience members have with their pharmacists influences perception and the Star Ratings of health plans, the collaborative relationship between care partners could use a little couples therapy.
While the notion “member experience” is somewhat elusive — and CAHPS scores don’t always reflect the quality of care — health plans are under immense pressure to perform well and deliver 5-Star care and service. For some plans, anything short of 4.5 Stars could hurt payer’s ability to stay operational, given the broader surge in chronic disease management and readmissions costs.
But what we do know is that member experience — and what members indicate on CAHPS surveys— is influenced by their relationships with all caregivers, not just physicians.
Pharmacy professionals are increasingly operating at the top of their licenses. They are more likely to administer vaccinations and offer guidance and counseling to patients than in any other time in history. In underserved parts of the country, sometime referred to as “physician deserts,” Americans may interact with their community pharmacy pros more frequently than with their regular doctors.
The bottom line: If patients receive exceptional service from their pharmacy, that will ultimately benefit the health plan. If pharmacies are cut back on staffing or service to offset PBM clawbacks, those cuts affect service. And if the quality of service declines, so does member perception.
Say a diabetic patient isn’t receiving their medication in a timely way because they struggle to obtain it, his or her outcome could worsen—as well as their perception of their experience.
The health plan and pharmacy partnerships that are built on collaboration are better poised for success.
With that in mind, here are three ways that health plans can work more collaboratively with pharmacies to boost member experience — and thier Star Ratings:
Pharmacies aren’t always privy to the internal policies or pricing decisions made by health plans, such as the amount of money they’ll be asked to repay for dispensing certain medications.
But having very visible value-based arrangements and programs with pharmacy networks could do wonders for improving communication in all areas (including discussions of initiatives to support high-impact quality measurement improvements).
An American Journal of Managed Care interview ofJoseph A. Albright, Pharm.D., manager of clinical pharmacy programs at Blue Cross Blue Shield of North Carolina, highlighted the dynamic when plans enter collaborative value-based arrangements with health systems. “Oftentimes there's an adversarial relationship when you first start out, when it comes to a payer and a provider because we're used to kind of butting heads,” Albright noted. However, Albright also said that his best relationships with physicians are ones where they are clearly involved in decision making and treated as equal partners.In the same way, value-based programs through direct arrangements with pharmacy networks can drive collaboration and performance.
When health plans, PBMs and community pharmacies are using different technologies to track supply chain management, medication administration and patient care, it can be difficult to monitor progress that’s tied to performance (e.g., adherence, influenza shots administered, drug plan satisfaction) and engage members in a coordinated way. Using an integrated clinical care management platform can help optimize medication use, oversee care management, reduce avoidable healthcare expenses and improve reporting for compliance and quality performance purposes.
Health plans regularly analyze data sources such as CAHPS data and their own prescription claims data to find the most obvious opportunities for improving performance. But they don’t always communicate their findings through these deep-dive analytics exercises to their care partners. This is a mistake, because there are many low-hanging fruit opportunities for pharmacies to work with health plans to improve care and service. Once value-based intervention arrangements are in place and operating through integrated clinical platforms as discussed above, the platform exists for very visible focus on pharmacy-specific mutual opportunities for improvement.
Without having to guess, pharmacists can do what they do best — problem solve. For example, if the Part D measures for adherence are lower than expected, pharmacy partners may have easy “fixes” in mind, such as rolling out a new webchat or automated refill service that could help patients obtain needed medications on time and more easily help out with that “Getting Need Prescriptions” measure a little too!
Working together to achieve common goals will become more important among all healthcare stakeholders as value-based care takes hold across the country.
When health plans and pharmacies embrace a collaborative relationship instead of an adversarial one, both are more likely to succeed with CMS’s Star ratings program and other quality initiatives, and that success translates to more members who are satisfied with their care and stay enrolled with their plan.
Anna Hall, PharmD, BCACP is the drector of quality services at Transaction Data Systems, a pharmacy technology and analytics company.