Pharmacies, Interoperability, Star-Ratings and Automated Pharmacy Dispensing

Category: Pharmacy Success Written by Dr. Charles Shively / November 11, 2014

Interoperability and Patient Portals

WOW… pharmacy is advancing healthcare and has changed the healthcare ecosystem in the last two (2) years. Surprised?

Yes, pharmacy and its professionals are now involved with previously distant concepts of QR codes, telepharmacy, eMobility (apps for android/iPhone and tablets) and medical homes including opportunities for patient portal linkages with their physician offices and hospitals. Which pharmacies here are linked in a community patient portal?

To those who have attended recent conferences regarding opportunities to utilize telepharmacy and eMobility and supporting eHealth and ePharmacy, it is now…clearly… time for involvement.

Pharmacy has recently experienced a unique new type of bonding with the healthcare insurance payors and PBM’s (pharmacy benefit managers with whom pharmacies also align) who support prescription co-pay reimbursement. Today, healthcare plans and PBM’s need pharmacies to also be “ high level performing stars” which supports the performance star-ratings that healthcare plans and PBM’s need… to qualify for the CMS (Center for Medicare and Medicaid Services) yearly financial bonuses available. WOW…New Age?

The new CMS star-rating system for healthcare plans and PBM’s have caused a shift in the always in-place (since 2006) level of co-dependency between individual pharmacies and their healthcare adjudicators (for prescription filling reimbursement) and Medicare.

Unknowing to many pharmacies, their performance in unique patient support areas impacts the CMS (Center for Medicare and Medicaid Services) performance (and dollar bonus/reimbursement) to those high-performing health care plans that attain a “ 5” star rating. Healthcare insurers need high ratings to effectively manage co-payments and deductibles…offered to their insured customers. Have you noticed how healthcare insurers are marketing directly to their subscribers and often using their star-rating status as a lure?

How Is It This Works?

CMS has defined various performance goals for Medicare healthcare insurance plans. It’s a star-rating system…1-5 stars. Less than 3, the plan typically will not qualify for a performance ($) bonus and risks access to lure new assureds. Performance ratings are updated each Fall and listed on www.Medicare.gov/find-a-plan. The performance assessments for healthcare plans measures how well health plans and prescription drug plans perform on more than 50 items, which are grouped into different categories. More information about the star-rating system is available at www.medicare.gov/Pubs/pdf/11226.pdf.

After years of being the lesser co-dependent player in the pharmacy-healthcare plan relationship, pharmacy now can greatly impact a particular healthcare plan star-rating. How? By focusing attention on patients with diabetes, cholesterol, drug-drug interactions and high risk medications…including (importantly the new surge) chronic illness patients.

How Does Automated Pharmacy Dispensing Support Better Health Plan Star-Ratings?

Automated Pharmacy Dispensing allows TIME to do the important assessments that support patient health. Any pharmacist knows the time to do “this and that” in pharmacy workflow can decrease patient interaction and subsequent development of the patient/customer’s involvement in the emerging “I’m Helping Myself” approach many patients now embrace to impact their personal healthcare. As most pharmacists know, pharmacy patient/customers are now part of the direct-to-customer marketing involved with “patient nation” approaches by health care plans and pharmaceutical product manufacturers. Yet, pharmacies and their presence through various avenues… including social media and eMobility…can impact improvement in medication adherence, medication therapy management (MTM) and medication synchronization (all monthly prescriptions filled at the same time) that offers star-rating improvement for their pharmacy and the healthcare plans with which they network. These efforts demand TIME for both pharmacist and certified pharmacy technicians to advance the star-rating… use and involvement of an automated pharmacy dispensing system creates this TIME.

The Link Between Insurance Plans and Pharmacies

Seem odd that today insurance plans, PBM’s and pharmacy adjudication networks are dependent on pharmacy performance? It is, as they say, a New Age. The pendulum swings from left to right (right to left?) as healthcare adjusts to the needs of its clientele. Pharmacies now have performance dashboards to assess their performance in meeting the CMS start-rating system and their local pharmacy practice value as perceived by their customers.

Recent visits to Southeastern United States pharmacies have confirmed the challenges that pharmacy today now experience…particularly independent pharmacy owners…is linked to the necessary medication adherence, medication therapy management and medication synchronization (monthly refills) offered by pharmacies. All of these opportunities for customer/patient involvement, are advanced by automated pharmacy dispensing and its subsequent creation of TIME for the pharmacist and certified pharmacy technician.

Do you automate? Count Less…Do More and as is well-known today…”You can’t win unless you play”.

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Thank for sharing!

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