Inmar Inc. | February 26, 2015

The rapid pace of change in the healthcare industry is dizzying. The ever-growing list of new wrinkles brings new complexities to the pharmacy industry. When you consider changes spawned by the Affordable Care Act (ACA), Medicare changes, private plan changes, drug price changes, the sprint to specialty pharmacy, it's almost enough to make you want to run for cover.

An even harsher reality comes with those challenges: More than ever, the healthcare industry is feeling the crushing pressure of larger economic forces outside its industry. The challenges of getting paid for products and services rendered have grown.

But, the ACA changes that, doesn't it? Think again. People who couldn't afford health insurance before ACA now have more affordable coverage, but now they have something else they didn't have previously. They have new expenses. ACA makes the overall umbrella of health coverage available, but with it come out-of-pocket expenses like patients' share of the bill, copays for office-visits and procedures, and drug copays. People who didn't have the money to pay for insurance before may not be able to afford to have it when they have to face the out-of-pocket expenses.

What does that mean to the pharmacy industry? For one thing, it adds another wrinkle to the challenges and industry costs associated with medication adherence, especially as pharmacies are added to the ranks of those accountable for patient outcomes. People who didn't previously pick up meds because they couldn't afford them may still not be able to pay, once they've paid the clinic that wrote the prescription.

Before the advent of mandated electronic health records (EHR), if someone knew they couldn't afford to pay for a prescription, that paper prescription often didn't see the light of day at the pharmacy. With new Meaningful Use mandates to e-prescribe, prescriptions come into the pharmacy whether the patient can afford them or not.

So, prescription abandonment becomes a bigger challenge: even if the patient never intends to pick it up, the pharmacy still gets the order and incurs the costs of time, labor and supplies to fill it with no knowledge of whether someone's coming to get it. That creates an additional challenge on meeting med adherence goals for Five-Star ratings.

A study published last year in the Annals of Internal Medicine indicated that 31 percent of all initial prescriptions were not filled within nine months. The good news is that for the 69 percent who do fill those prescriptions, outcomes should improve with new patient-education and med reminder initiatives. The bad news is that with those first-time prescriptions not picked up, there's no electronic record from the claims process that allows medication adherence to be tracked. There's no crystal ball to predict primary med nonadherence (PMN) — yet.

New quality measures introduced by the Pharmacy Quality Alliance in 2013 should represent metrics that will help to better define PMN so better interventions can be developed. It will be interesting to see how those interventions shape up as we begin to learn more about how previously uninsured patients handle the new financial challenges they may face with being insured. While those developments shake out from an operational cost and outcome-intervention standpoint, pharmacies will have to ensure they're doing the best possible job of following the money in the everyday business with people who do pick up their meds.

Remember, more insured patients means more transactions — the volume of those new transactions alone represents a lot of vital revenue riding on a financially at-risk population. Along with increased volumes comes the growing list of financial, regulatory and reimbursement challenges pharmacies are facing, the current environment underscores the importance of putting emphasis on pharmacy financial management. Chasing down the money has always been a challenge, but in this dynamic environment it's paramount.

Pharmacies need to make sure they have the tools to manage reconciliation of payment. With the sheer volume of prescriptions and the increasing number of plans they're submitted to for payment, it can look close to impossible to identify, understand exceptions and bring in the money. When you submit anywhere from thousands to hundreds of thousands of transactions per day, how are you making sure you're tracking and resolving missed checks, no-pays, partial pays, potential pays and denials? To say it's a daunting prospect is an understatement, but there are tools and resources available to keep you on top of it.

The technology to help you sort, understand, identify and collect from the areas listed in the previous paragraph is well worth the investment when you consider it's a matter of intervening in your 60-to-90-day unpaid accounts receivable bucket to keep those transactions from becoming bad debt or unrealized revenue.

Another way the investment in technology is a valuable move is in being able to reduce risk through more comprehensive accounting reports and utilize trending and reporting analytics to give you complete visibility into all of your liabilities.

The pharmacies that survive the current crunch and thrive in the new landscape will be the ones that invest in the necessary time and resources required to manage all claim type receivables in a single-source, efficient manner. I'd say Gladys wouldn't be able to make enough coffee to track down and report out on third-party payers, cash, discount cards, AWP resubmission claims, specialty, professional services and patient receivables. And, she'll probably scream if you ask her to parse-out accounts receivable reports by payer, by age, by category to identify and strategize recovery efforts to avoid bad debt.

So that brings me back to ACA and patients who can't pay. Where does this technology and pharmacy accounting infrastructure fit into that equation? With solid technological solutions crunching the numbers, you can leverage providing the power of reporting and recovery strategy support. The right technology means you have the kind of data you need to identify operational efficiencies and process changes that make it easier to identify those med-adherence risk patients and perhaps not fill their prescriptions until they come in. So you never incur the costs of labor, bags, labels and ink to print the millions of prescriptions that go unfilled each year.

The current environment of constant change is definitely filled with challenges, not the least of which are financial. And, although those challenges may appear to be in the hands of the rule makers, the solutions will be in the hands of those who seek out the tools to meet those challenges.

What ideas do you have for solutions to these challenges? Please share your thoughts in the comments section below.


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