Q&A: Value-Based Care is Reshaping Pharmacy’s Clinical, Financial Future

The days of pharmacy’s financial survival hinging almost entirely on dispensing volume are numbered. For forward-thinking pharmacies willing to embrace value-based care, this shift represents one of the biggest opportunities the profession has seen in decades, impacting both clinical services and financial sustainability.

“My best answer is [value-based programs are] coming regardless,” said Kevin Day, PharmD, managing network facilitator at CPESN Ohio and president of Day’s Pharmacy in Glendale, Ohio. “How we are preparing for it and thinking about it and understanding our position on these broader teams and positioning ourselves to be able to participate is really where the future’s going to be for that space.”

In part 2 of our interview with Day, we sat down to discuss the Pharmacy Quality Rewards Program in deeper depth. As a key steward of the program’s partnership between CPESN USA and Human Healthy Horizons in Ohio, Day provided us with key insights into the evolution of value-based care.

Read though this discussion to see how value-based care and sustainable pharmacy initiatives have the potential to transform both the way patients receive care as well as how pharmacies stay afloat financially.

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Drug Topics: What is so unique about value-based care initiatives like this one and why do you think they are continuing to rise in prominence within the pharmacy industry?

Kevin Day: There’s an interesting answer to that because there’s almost a tongue-in-cheek way to answer the question that I think is at least partially true. The reason why these are growing is because the federal government says these shall grow. We still live in this world where we all follow what Medicare says. I remember when I was in DC, President Obama had laid out a vision and a goal that something like 50% of Medicare payments they wanted tied to a value-based arrangement as early as 2014 or 2015. And that number expected to grow to 80% in the late 20-teens timeframe. That’s the world we live in.

The right answer to this question is this is how health care works now; things get tied to value, period. If pharmacies and pharmacists want to be providers and be part of the team and be treated in this way, we have to be comfortable in this and fluent in this and be able to understand what this looks like. We’ve talked for 15 years now in pharmacy worlds about pharmacist provider status in Medicare. Many states have that now in Medicaid. There’s lots of opportunities in the commercial space where pharmacists can bill for services. What that has been, though, is being able to bill for services.

Really where that is now is play in the value-based arenas. I don’t think there’s any way where this isn’t part of the future, where value-based arrangements are getting applied to what we’re doing. And I don’t think anybody should want anything different. That’s maybe personal opinion, and I could probably have an argument of the directions. There is actually a moderate amount of evidence that a lot of the big, looked-at-as-successful value-based programs haven’t really moved the needle very much on things like total cost of care. That said, I have a hard time believing that that’s not a future state that we’re going to figure out as a country, as a world. I think it comes really back to that; are we providing aligned care, where incentives are actually aligned all the way through?

There have been, because they were easy to measure, some value-based care programs across lots of places where the thing that was being measured was some process measure. It was measurable, so we measured it. And it got better because it was able to get better. There’s whatever that rule is that whatever gets measured gets better or gets improved on. But if it wasn’t all the way aligned through to a true patient outcome, it may not move the needle.

Getting to these kinds of arrangements where the outcome is a solid clinical measure, it still isn’t the end all be all; have A_1C under 8. If somebody goes from 8.1 to 7.9, not a lot has changed, but if we talk about this person who started this program at 12, if they get all the way down to 7.7, that would be great. I don’t think it’s arguable that they would be in a better space. I guess that’s my best answer here is this is coming regardless. How we are preparing for it and thinking about it and understanding our position on these broader teams and positioning ourselves on these broader teams to be able to participate is really where the future’s going to be for that space.

Drug Topics: Whether it be shifting the focus to value-based care or seeking out new partnerships within their communities, how do you envision initiatives like the Pharmacist Quality Rewards program to encourage other pharmacies and pharmacy professionals to enhance their clinical services or business models?

Kevin Day: I guess I’m hopeful. People who know me well know I’m a pretty hopeful kind of person. This comes out for me a lot.

Maybe this is part of a program that really starts to change how health care works and how pharmacy works in general. What we’ve laid out right now for this particular program, these are Ohio Medicaid patients. The dispensing side in the pharmacy is stable. We get paid in a cost-plus model that works. It’s not going to get anybody really that rich, but it also isn’t going to put pharmacies out of business. So, we have sustainability on dispensing. Yes! We should celebrate that.

Because of the provider status piece, we have the ability to bill for enhanced services. If you’re a pharmacist in a team and a company that wants to go above and beyond and do care management and other kind of work in your pharmacy, you have the ability to bill for that. That, again, makes those sustainable. Traditionally, pharmacies who wanted to go above and beyond were giving that stuff away or trying to charge patients for it. Now, that space becomes, again, sustainable. These are Medicaid rates. You’re not getting rich on them, and it’s 85% of the fee schedule right now in Ohio for pharmacists. But it adds a sustainability piece. Then, with a value-based-care kind of cherry on top, it’s a framework that I feel like can work and can scale.

What has to change for the future, for this to be really successful, is the cherry’s got to get a lot bigger. This means we need a lot more people involved. The challenge for us as a network is to perform this year. Then, [we can] convince other Medicaid plans to start to play in this space, both in Ohio and then across the country. That scenario is dispensing is fair, there’s sustainability and process and ability to pay for services, and the best pharmacies get rewarded.

Right now—not that this is a negative, it’s just how the incentives work—the biggest pharmacies make money. They make the most money because they buy the best, they can drive efficiencies of scale, all of that. Whether that’s your big chains, your big grocers, your big mail orders, or your big independents, there’s plenty really big independents that are pushing volume and making really good money. It’s good for them; they can do lots of things in their community. Many of them are reinvesting and doing amazing work, and we shouldn’t dismiss that.

What isn’t tied together into that, though, is that the best pharmacies really have the opportunity. Getting someone’s A_1C to goal requires work, good communication, trust, cultural competence, and all of this backend effort of a team to get someone to goal. If pharmacy A gets 80% of their patients’ diabetes under control, and pharmacy B only gets 40%, good. Pharmacy A should get rewarded in a real way. Wouldn’t it be great if it was thousands and thousands and thousands of dollars for that to potentially happen? That’s the mindset, framework, and thought process that we’re bringing to this particular program; that we bring to the value-based care programs in general.

Then, it should be able to scale across all disease states. That’s a big piece of my frustration. Most of the—I’m going to call it still early, even though they’re 15 years old—value-based care programs that are based on adherence to statins and ACEs and ARBs [are] cool. How do we figure out how to do adherence and success with Zoloft? It comes back to the PHQ-9s (Patient Health Questionnaire). How do we work in what’s totally changing the world right now with SGLT2 inhibitors and GLP-1s? The drugs are moving so quickly, it’s hard to build value-based care programs that follow. But if you stay on big outcomes, I think we can. And how do we all play in that role?

We can’t do it at small pharmacies. The network role is a must at some level. Whether it’s CPSN or not, doesn’t really matter, [it’s] the recognition of [something] like, it doesn’t matter if my pharmacy happens to be the best at anything because I’m [just] 2 locations in suburbia Cincinnati. I can’t move anybody’s needle in any real way. Coming together, playing together in that sandbox, to be able to move needles together, I think is really where that future comes, and really continuing to challenge it. If we get sustainability on the bottom, on the dispensing piece—again, we’re starting to make some real progress, both in Ohio and across the country—we can actually start to bill towards other things where we’re key parts of people’s health care teams and really taking care of people’s goals, helping them towards their goals for a healthier life. That’s what we all want to be doing. Let’s set up some systems that can actually help us get there.

Hopefully, this program is maybe step 1 for us in Ohio and maybe a big step for others to mimic, copy, and learn from. Obviously, we’re early. We’ll see what this looks like. But we’re pretty confident that we have a real chance to make a difference in people’s lives and meet the metrics laid out, certainly in the program for us, and then be able to scale from there.

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