Hybrid Payment Models: Unlocking Sustainable Revenue for Pharmacist-Led Clinical Services

Community pharmacies trying to grow clinical services should stop picking between fee-for-service billing and value-based care and start combining them. That was the main message from Jason Ausili, PharmD, MSLS, director of clinical business development at AlignRx, in a presentation at the Total Pharmacy Solutions Summit Fall 2026.

Ausili said pharmacy is moving away from a margin-squeezed model built around dispensing. Clinical services now help make up for those shrinking margins, and he predicted that clinical revenue will one day come close to dispensing revenue, "and hopefully someday surpasses."

Still, many clinical programs fail. According to Ausili, the problem is money, not knowledge or training. "It's not pharmacy education. It's not pharmacist or pharmacy technician knowledge skills training. It's the revenue, the unsustainable revenue," he said. He added that other barriers include not knowing how medical benefits work, a "one project mentality," and relying too much on grants.

Two Models, One Strategy

Ausili called fee-for-service medical billing "the workhorse." It uses CPT codes sent on 837P professional claims to pay for immunizations, medication therapy management, point-of-care testing, and office visits. It's predictable and timely. However, revenue depends on volume, and the model "may incentivize more encounters over positive patient outcomes."

Value-based care, which includes pay-for-performance, shared savings, and per-member-per-month programs, works the other way. "Fee for service pays for the work. Value-based care pays for the results of the work you did," Ausili said. Its upside isn't capped, but it's more complex to run, needs strong data reporting, and depends on patient behavior that pharmacists can't fully control. "You can't make Susie, you know, take her insulin regularly every day," he noted.

"Neither model alone creates the ideal long-term strategy," he said. "Together, they are much stronger."

In a hybrid model, a single patient can bring in several kinds of revenue, including billable assessments, follow-up visits, and testing, plus bonuses for adherence and quality. Ausili called this "a self-reinforcing growth cycle." Fee-for-service income pays for staff, more staff time leads to better outcomes, and better outcomes earn more incentive payments.

Starting With What Pharmacies Already Do

Ausili recommended cardiovascular and diabetes care as starting points, because pharmacies already serve large numbers of these patients. Services could include risk assessments, medication optimization, blood pressure and cholesterol monitoring, and A_1C testing. The key difference is documenting care and tracking progress toward goals. "If it wasn't documented, [it] didn't happen," he said.

To make the case to payers, he pointed to adherence data. Half of patients on chronic medications aren't adherent. Better adherence is linked to 31% lower odds of ER visits and 60% lower hospitalization rates. "This is the value prop to the payer that should open up value-based payment," he said. He also noted that 90% of Americans live within 5 miles of a pharmacy.

He urged pharmacies to choose a medical billing solution before launching any service, to get the whole team on board, and to use existing documentation templates. He also recommended working with networks such as AlignRx or CPSN rather than going it alone.

"The pharmacies that win align patient outcomes with financial sustainability," Ausili said.

Explore more of our coverage from the Total Pharmacy Solutions Summit Fall 2026: Patient First.