Be Prepared! Payments for Pharmacy Services Are Changing

Category: Pharmacy Advances Written by Dr. Charles Shively / January 13, 2017

Are you aware of the changes forthcoming to the New York State Medicaid Payment System? Your financial future will soon be “in the balance” if your pharmacy operations management system and software are not in tune with the forthcoming New York State Delivery System Reform Incentive Program (DSRIP) set to implement a little over one year from now.

shivley mapThe DSRIP program, designed to manage the overall health expenses (claims) by Medicaid and Medicare users in New York State will also allow the value based payment contractors established by the State(managed care organizations, commercial insurance payors, physician practices, hospitals, etc.) to increase their margins by realizing value…and not volume. The DSRIP program is a pay for value not volume approach (unlike the current model of fee for service). This pay for value approach (also known as value based payments-VBP) incentivizes provision of quality care and coordination between all care delivery players for each patient or customer. Pharmacy is included!

So why is this a “big deal”? Unless pharmacies can prove they are completing and documenting the many different pharmacy professional interventions which will be required (performing MTM or medication therapy management, using medication synchronization, completing follow-up drug compliance and others), the overall preferred provider performance ratings and claim reimbursement rates in the contracts established with the State will be impacted. The pharmacy services rendered…obviously much more than just prescription filling…will need demonstrate and support measureable improvement to a patient’s condition as part of an integrated clinical partnership. Those pharmacies that can allow the preferred providers to see performance data real time…by patient served…will be judged as star performers.

Poor performance reviews of an insurance provider by the Center for Medicare and Medicaid Services (CMS) reduces the amount of bonus money or increases the fines that a particular insurer will receive or incur as a result of the mandated yearly reviews by the Affordable Healthcare Act and typically causes insurance premiums for each insured within that plan to increase.

How is it then will the individual pharmacy demonstration of improvement (to the individual patient performance) be judged? The current Star Rating system is already being used by major commercial insurance companies to “weed out” those pharmacies which cause their overall performance reviews by CMS (Center for Medicare and Medicaid Services) to be below standard and not 3 stars or higher (5 stars is highest). The key pharmacy performance areas are patient engagement and satisfaction approaches including interventions such as medication synchronization, medication adherence and medication therapy management specific to the targeted health prevention and continued conditions or diseases outlined by CMS.

Good news however! As part of my 2016 Healthcare Advocate Tour I discovered an integrated pharmacy operations management system (PCOSRx) that includes a powerful integration tool called Prescribe Wellness. This specialized component of the total POCSRx system is a powerful additive and offers realtime support in the areas of patient engagement, pharmacy growth, star ratings, Medicare Part D plan options (specific to the individual patient) and compliments the daily revenue opportunities defined by POCSRx.

How is it the complete POCSRx system, which now includes this application, improves daily operational financial success and Star Ratings?

Techniques to identify patients who are underperforming and impact the pharmacy Star Rating is just one “click” away. The steps to take to improve patient adherence can be quickly identified through extraction from the pharmacy system data and are presented for action. Patient communications can be streamlined to improve patient health outcomes and increase customer loyalty…without altering the day to day routine. The system provides the tools to deliver timely, relevant communications to patients. It allows these events to be completed in your voice…the same voice they hear when they are in the pharmacy. The result is increased prescriptions fills and monthly revenue by using event campaigns to increase customer awareness and participation. The clinical refill reminder feature improves medication adherence and reduces the number of prescriptions being returned to stock with improved will call bin management. What is the end result of these techniques? You and your pharmacy are in front of the patient nearly continuously improving loyalty.

Non-adherent patients directly impact a pharmacy’s performance metrics and subsequent Star Rating. Being able to identify and take action on patients that negatively impact Star Ratings is a key feature of the POCSRx- Prescribe Wellness combination software. One can easily recruit and enroll patients in the POCSRx medication synchronization effort through the pharmacy’s electronic calendar and automate communications in your voice for things like 7 day out and reminder calls. Integration of transmission of refill and Short Fill fax requests do not require time consuming searches but are easily available due to rapid computer data review. Synced medication will be pushed into the workflow queue…and improves Star Ratings for the pharmacy.

As I am sure you agree, Seniors represent a major portion of the daily revenue opportunities in most pharmacies. Being able to identify a Medicare plan that is matched to the individual patient’s medication needs is just one of the abilities of the complete POCSRx system. A pharmacy can now identify, display choices and allow recruitment of seniors to your pharmacy in your voice to share the findings. Patient engagement and patient loyalty is the result.

Is your pharmacy prepared to use this new value payment approach to claims payment in the State of New York?

How long will it be before all claims to commercial insurers, in general, will also follow this approach across the United States?

Let’s improve the quality of healthcare with our professional interventions. We can do it.


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Thank for sharing!

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