Value-Based Pharmacy Model Helps Boost Care Quality

Ben Shirley, senior director of performance measurement at PQA, explores how community pharmacies can thrive in value-based care by shifting away from fee-for-service reimbursement and focusing on measurable improvements in patient outcomes. He explains that traditional pharmacy payment models reward dispensing volume rather than health impact, which is unsustainable as health care moves toward quality-driven incentives.

In this pilot, PQA and partners test standardized, validated pharmacy quality measures that can be consistently applied across programs and payers. Instead of each health plan or pharmacy benefit managers using its own metrics for services like blood pressure control or immunizations, the goal is to “do it once, the right way” with harmonized measures that support scalable value-based pharmacy arrangements.

Immunizations, especially flu vaccines, are highlighted as a prime opportunity for pharmacies to demonstrate value. Flu is relatively straightforward to measure on an annual basis, and pharmacies see patients far more frequently than physician offices, making them ideal touchpoints for closing care gaps. Interestingly, the pilot found particularly strong performance improvements for Tdap, which may face less public controversy than flu and other vaccines.

Shirley also addresses the technical and operational challenges of moving beyond claims-based measurement. Although some advanced community pharmacies can share clinical data using standards like eCare Plan, many payers still lack infrastructure to receive, audit, and use that information, reflecting broader interoperability issues across the healthcare system.

To accelerate adoption, PQA is developing the Pharmacy Quality Recognition Program, a national framework to recognize pharmacies committed to continuous quality improvement, patient-centered care, and value-based performance. By showcasing robust immunization rates and other outcomes that reduce medical spend and improve health plan quality ratings, pharmacies can better communicate their value to payers and secure sustainable value-based contracts.

As pharmacies think about where they can really plug into team-based care and leverage what's unique about their model, having those touch points [and] being able to close those gaps where there is so much opportunity for improvement is a really good data point and communicate that value to the payers that you work with as a pharmacy,” Shirley said.