Independent pharmacies can influence how well plans and pharmacy benefit managers (PBMs) score on their performance metrics. In turn, PBMs evaluate their pharmacy partners using clinical and operational metrics that directly affect payer reimbursement.
One of the biggest challenges for independent pharmacies is understanding how they’re being evaluated, then taking the appropriate actions to improve in the areas of highest interest to payers. By taking action and with improved performance, pharmacies can:
- Gain access to preferred pharmacy networks
- Improve care for patients and customers
- Create new revenue opportunities
- More effectively manage operating expenses
To receive those benefits, your independent pharmacy should take the following five steps.
1. Review and understand all payer performance requirements
Your independent pharmacy must know how it’s being measured if you want to know which areas to focus on. PBMs typically specify in each reimbursement contract with a pharmacy the measures that they will use to evaluate the pharmacy’s performance.
Your pharmacy can also seek assistance from your pharmacy services administrative organization (PSAO). PSAOs have information in user-friendly formats and break down metrics by type and weighted percentage. Most metrics fall into two buckets, including clinical and operational measures.
Some examples of common clinical measures are:
- Medication adherence rates for disease states like diabetes, hypertension and hyperlipidemia
- Gaps in recommended care like annual statin use in patients with diabetes
- Completion rates for comprehensive medication reviews (CMRs)
Some examples of common operational measures are:
- Generic efficiency, which is filling with a generic option when a generic drug is available
- Compliance with an approved drug formulary, which is the ability to fill prescriptions using medications preferred by the PBM
- 90-day prescription fill rates, which is the ability to replace three 30-day supplies of a prescription medication with one 90-day supply
2. Measure and monitor your own performance against payer requirements
Once your independent pharmacy knows the criteria on which it’s being judged, the next step is tracking how well it's doing against the criteria. Pharmacies can use technology to help them with the self-evaluation.
The majority of PBMs use a system called the Electronic Quality Improvement Platform for Plans and Pharmacies, or EQuIPP, to track their performance. EQuIPP has a dashboard that displays scores on different health plan, PBM and pharmacy performance measures. Your pharmacy can access the dashboard to check its scores and identify areas where you can take action to improve.
Some payers don’t use EQuIPP. In those instances, the PBMs can send their own reports to your pharmacy to let you how well it's doing against the criteria.
3. Use technology to identify patients who are negatively affecting performance scores
Your independent pharmacy can leverage EQuIPP to identify individual patients who are having a negative impact on performance measures for a specific health plan or PBM. Pharmacies that don’t use EQuIPP can use applications in their own pharmacy management systems to help them identify non-adherent patients.
By utilizing technology, your pharmacy can pinpoint patient “outliers” in each plan or PBM. For example, outliers could be patients who are identified as being nonadherent to prescription medications or at risk of becoming nonadherent.
They are also patients whose current medication is not an approved formulary medication, or those not taking advantage of a 90-day fill option.
4. Engage patients who are outliers to help change their medication behaviors
After your independent pharmacy identifies patients who are affecting its performance on various clinical and operational metrics, it’s time to act. The data creates opportunities for your pharmacy to engage outlier patients in each plan or PBM about their medication behaviors and preferences.
Some examples of patient engagement for clinical measures include:
- Work with patients to identify specific barriers preventing them from taking medications as prescribed
- Use motivational interviewing to ask patients open-ended questions to identify adherence issues
Once an issue is identified, your pharmacy can tailor solutions to overcome the specific issue. If access or transportation is a challenge, delivery and/or enrollment in an appointment-based med sync program might be appropriate. If cost is an issue, an alternative, less-expensive drug or co-payment assistance from a drug manufacturer could help.
Some examples of patient engagement for operational measures include:
- Increase generic efficiency by educating patients on the availability of generic versions of brand-name drugs and offering the generic alternative.
- Improve 90-day fill rates by explaining to patients that they could have one co-pay rather than three—one for each 30-day supply.
- Improve formulary compliance by ensuring pharmacy staff is aware of drug formulary changes for each PBM, including updates and alerts from pharmacy management systems and ongoing staff education.
5. Use improved clinical and operational scores to reduce costs and increase revenue
Your independent pharmacy should see improvements in its performance scores on clinical and operational measures after following the first four steps. Your pharmacy can leverage those improved scores to reduce costs, create new revenue opportunities and improve patient care.
For example, many PBMs base the DIR fees they charge to pharmacies on how well pharmacies perform on clinical and operational measures in their contracts. Pharmacies that improve their performance on the measures will decrease their DIR fee liability and lower their operating costs.
On the revenue side, improving medication adherence rates will increase your pharmacy’s revenue because more prescriptions are being filled. Some plans and PBMs are starting to reimburse pharmacies for achieving medication adherence targets as part of pay-for-performance reimbursement contracts. Additionally, some of the services your pharmacy provides to improve medication adherence like CMRs and other medication therapy management are often reimbursed separately.
The five steps won’t be effective unless your independent pharmacy fundamentally changes how it operates. Your pharmacy must be proactive rather than reactive, especially when it comes to chronically ill patients being adherent to their medications. Your pharmacy also must be willing to measure its performance on an ongoing basis and make continuous improvement where necessary.
If your independent pharmacy can make those commitments, the five steps provide a path to sustainable clinical and business success.
Related: Read more about Web2pro’s growth and expansion solutions for independent pharmacies