NCPA Executive Update

NCPA Executive Update delivers insights on legislative, regulatory, policy, and industry developments from NCPA CEO B. Douglas Hoey, Pharmacist, MBA, to NCPA members and pharmacy leaders every other Friday.

Value-based payments closer for RPhs | NCPA Executive Update | February 19, 2016

by NCPA | Feb 19, 2016

February 19, 2016

Value-Based Payments for Physicians Are at Hand—Can Those for Pharmacists Be Far Behind?

Dear Colleague,

Doug Hoey

Payers and providers agreeing on payment issues is akin to a lion lying down with the lamb moment, but this week the federal government, major commercial health plans, physician groups including the American Medical Association (AMA) and other stakeholders saw eye-to-eye on significant changes to how health care providers will get paid.

It's one more sign that all of the talk about health care providers being paid for value is not just talk. This change is just starting to affect the day-to-day operations of pharmacies, but it's just beginning.

Tuesday, Centers for Medicare & Medicaid Services (CMS), America's Health Insurance Plans (AHIP), and a coalition of health care system participants released seven sets of clinical quality measures.

Physicians agreed that part of their payments will be based on measures such as how well patients manage their blood pressure as well as readmission rates for patients with certain conditions like a hip replacement.

What does it mean for pharmacists? This is part of the wave of "value payments" that I cited in a couple of Executive Updates last year (Dec. 18, 2015 and Jan. 30, 2015). In both, I mentioned that CMS and other payers are moving toward a reimbursement model to reward the patient's outcome instead of paying for only the volume of services. More simply put, it is payment based on quality rather than quantity.

Hospitals already have payments tied to quality outcomes. The first stages of value-based payments for pharmacies have already begun via the Medicare Part D star ratings. In addition, pharmacists are moving toward CMS recognition as providers in underserved areas, which can only accelerate value-based payment expectations. Legislation in Congress to accomplish that has broad and deep congressional support and pharmacist provider status has a real shot at passing this year.

Physician support of payments tied to these quality measures is just one more sign of the direction all of health care is moving.

For now, community pharmacies can advance their position in the value payment arena by doing their MTM cases and helping their patients be more adherent to their medications. Medication synchronization is a much more familiar term than it was nearly 10 years ago when NCPA began sounding it out as a call to action for pharmacists. More than 100,000 patients in 2,600 pharmacies have been enrolled in NCPA's Simplify My Meds® program and many more med sync programs have been created. In fact, according to the 2015 NCPA Digest, sponsored by Cardinal Health, found that some 70% of community pharmacies are offering adherence services to their patients. NCPA also has prepared a video series "Rethink Pharmacy," sponsored by H.D. Smith, which helps prepare pharmacists for practice evolution now and beyond.

MTM and adherence are the basics. A network of community pharmacies with the ability to form an interoperable network of pharmacies that can exchange pertinent data and assure predictable and measurable pharmacist services will be needed. One great example of such a network is pharmacy network that works with Community Care of North Carolina. Other networks like this are being pursued in other states.

While these changes are unfolding, NCPA cannot and will not lose sight of the here and now issues community pharmacies are facing. According to our annual member survey, slow and low MAC price updates, limitations to patient choice of pharmacy, and direct and indirect remuneration (DIR) fees are your top advocacy priorities. We will not back off our efforts to balance the one-sided business relationship between PBMs and community pharmacies. Marketplace solutions are our preferred approach but given the one-sided nature of PBM contracts, federal legislation and regulation will continue to be pursued and state legislation will continue to be promoted so that community-based businesses can help stimulate local economies and better serve their communities now and into the value-based payment future.

It's clear where health care payment trends are going. The value-based payment writing on the wall is there for pharmacists to take steps now to be well positioned while simultaneously fighting the PBM-initiated DIR and MAC battles.


Doug Hoey