Value-based care an oppportunity for Rx

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In recent years, the health care industry in the U.S. has accelerated its shift from fee-for-service toward value-based care (VBC) models, focused on holistic, long-term outcomes for patients and lower costs for the system. This shift was spearheaded by the Centers for Medicare and Medicaid (CMS) through legislation enacted between 2008 and 2019, notably by the 2010 Affordable Care Act. VBC models have already started to drive improved patient outcomes by leveraging broader care teams with the integration of social workers, case managers and other providers to supplement physicians.

Rodey Wing

But there’s still an area of opportunity: meaningful engagement with retail pharmacies. Partnerships between retail pharmacies and physicians and providers could unlock a critical communication and care checkpoint with patients. This shift will require pharmacies to rethink their operational and commercial relationships with providers.

Mind the gap: When health care players don’t coordinate, patients are left with poor outcomes

Today’s patient receives care from an ecosystem that includes primary care and specialist provider visits, financial coverage for care from their payor, and prescription fulfillment from their pharmacy. Pharmacies, providers, payors and patients are all stakeholders in this ecosystem, but when those stakeholders don’t talk to each other to coordinate systems, patient data and workflows, it’s the patient who loses.

Tonny Huang

Here’s an example: Today’s doctors are expending significant efforts to reach out frequently to high-risk patients to reduce their overall cost of care. But when those patients visit their local pharmacies, the information they share with the pharmacy team is not systematically collected and fed back upstream to support the care team. That missing data means physicians duplicate efforts to follow up on information that the patient has already shared, which takes a toll on physicians’ time to enable VBC — or worse, miss an opportunity to improve the outcome.

Reducing the burden on physician time is critical for the VBC paradigm to be successful. Currently, VBC prioritizes patient cohorts with the highest risk for negative outcomes, leaving patients within the next-highest risk cohorts underserved. The opportunity is clear: Leverage patients’ existing interactions with retail pharmacies as part of patient care coordination in order to expand equitable access to VBC models.

It’s time to expand the pharmacy’s role in patient care delivery

Retail pharmacies are one of the most frequent points of interaction between patients and the health care ecosystem, with some high-prescription-count patients visiting multiple times per month. The retail pharmacy can leverage those frequent personal relationships with patients to fill the gaps in health care coverage.

Laura Bowen

One example of the benefits from this coordination? Enabling an adaptive treatment plan based on the patient’s condition as it evolves. Providers can flag high-risk patients so that the retail pharmacy team engages the patient when they pick up their prescription refill. The retail pharmacy can then proactively check in on how they’re feeling and pass key data points regarding their symptoms upstream to provider teams. When the pharmacy staff enters that critical information, they automatically trigger provider workflows to adjust the patient’s care pathway to maximize the outcome while lowering cost. This model not only relieves the burden for providers via a lower cost channel for patient engagement, but it can also enhance the overall effectiveness by allowing for more frequent outpatient touchpoints. In either case, the efficiencies gained through this collaboration can be invested for the next-highest risk cohorts, improving the systemic VBC outcomes.

With increasing degrees of coordination, pharmacy services can further broaden to enable personal case management, proactive interventions throughout patient journeys, and shifting patient treatments to lower-cost pharmacy settings. Importantly, these expansions would not include net-new activities for the pharmacy. In many cases, the underlying technologies and processes are already in place to capture and flow information within the ecosystem. Pharmacies could also centralize or digitize administrative burdens for pharmacists to minimize the impact to pharmacy staff workloads and free up pharmacist time for the highest-value activities.

Tighter coordination requires a new model of pharmacy-provider engagement

Achieving this vision of end-to-end care, with close partnerships between payors, providers and pharmacies, will require change and investment, and it does come with operational challenges.

First, pharmacies and providers must work together to ensure electronic medical record (EMR) data is accessible and that workflows are synchronized across stakeholders. Right now, there isn’t scalable, off-the-shelf technology to sync data and workflows between providers and pharmacies. It will have to be built. Pharmacies can proactively partner with providers on integrations to leverage existing technical assets.

Second, there are commercial considerations. Stakeholders will have to align with each other on new ways to ensure payment flows across care delivery services to enable VBC reimbursement models, including reinvestments back into expanding access to additional high-risk patient cohorts.

Third, and critically, this end-to-end integration will require convincing both providers and payors that the pharmacy is a critical part of enabling the VBC paradigm at scale. If pharmacies can show a net positive patient care and financial impact, the industry will galvanize to adopt the pharmacy as a lynch pin of value-based care.

The challenges are clear, but so are the benefits, both to patient outcomes and to the ecosystem writ large. Retail pharmacies could be the catalyst that enables the VBC paradigm, but only if they engage providers in a fundamentally different way. When pharmacies are successful in being the point of coordination between providers and patients, everyone wins.

Rodey Wing is a partner in the health practice at Kearney, a global strategy and management consulting firm. He can be reached at [email protected] Laura Bowen is a principal in Kearney’s health practice. She can be reached at [email protected] Tonny Huang is a manager in Kearney’s health practice. He can be reached at [email protected] The authors wish to thank Sophie Sondhelm and Jonathon Asa for their valuable contributions to this article.


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