Inmar Inc. | July 18, 2014

Will the new quality-measure environment be burden or opportunity for pharmacies?

As health plans and Pharmacy Benefits Managers (PBM) put their quality programs in motion to get the best possible five-star ratings, the impact to independent pharmacies can actually be quite profound. In their hustle to keep ratings up to earn millions in CMS bonuses and rebates, health plans and PBMs will weigh preferred pharmacy network status with great scrutiny toward which pharmacies align with their quality measures.

What's at stake is more than just drug sales — it's revenue from the band-aids and vitamins and greeting cards and cosmetics and groceries and candy bars those patients buy when they come in to pick up their prescription. That takes this issue beyond simply being yet another CMS compliance matter and into the realm of competing and surviving as a business.

While five-star compliance is primarily aimed at health plans, some measures, such as comprehensive medication review, high-risk drug education and point-of service interventions for med adherence are very much in the hands of the pharmacist. Plans and PBMs will carefully scrutinize who gets them to the mark in their "drive for five," with preferred-network status in the balance.

Get cozy with health plan administrators and PBMs
We have to shake ourselves out of the old mode — the days of minor process changes for CMS compliance are gone. This new landscape involves activities that will impact services you provide, who you employ and how you market these new aspects of the business.

This response will not be without its challenges at levels of pharmacy operation not even connected to Medicare compliance. Consider the impact to the daily business of a pharmacy that gets a $60 reimbursement for a one-hour medication therapy management session involving a pharmacist who makes $65 an hour. That cuts it pretty close when you consider the potential for multiple sessions on any given day, and balancing such activities with everything else it takes to run a pharmacy during that hour.

Moving forward and gaining accreditation will mean pharmacies will need to adopt new means of performance measurement to ensure their quality improvements meet health plans' needs to hit the mark for their ratings and incentives. Software solutions are coming available that are pretty snappy in how they help you keep up on benchmarks, and they aren't free.

So is the new compliance environment all burden and no reward for pharmacies? Not necessarily. The situation presents a unique opportunity to deepen your relationship with your customers. Consider this: Patients — the ultimate driver behind the healthcare quality movement — have consistently ranked pharmacists among the most trusted professionals they interact with in any realm (second only to nurses in Gallup's 2013 poll). People have always trusted their pharmacist to advise and help them during their times of greatest need. The changing environment calls upon pharmacists to bolster the vital role they have always played in people's lives.

While all this change may indeed be money-driven from the business perspective of plans and PBMs, on the human side it's an opportunity to be the go-to resource that pharmacists have always been to the people in their communities. And depending on how you respond, that can translate back to a great benefit on the business side for your pharmacy.

So is it about keeping up just to survive? In some ways, yes. However, by staying agile with these changes and positioning yourself and your operations, pharmacies will find an opportunity to go beyond simply keeping up with the rules and the plans. This new environment affords an opportunity to actually play a leadership role in driving improvements in the quality and efficiency of care.

Add it up: The focus is on quality care. Consumers have always relied on you and blessed you with most-trusted status. Now, health plans and PBMs are counting on you as a key instrument in their survival as well. Surviving — and thriving — in the new quality-measure environment can either be a burden to pharmacies or an opportunity. What will it be for yours?

I want to know what you think about these challenges and how they stack up for your pharmacy business. Take a few seconds to give me your thoughts in the comments section below.


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