Q&A: How Pharmacists Stand in the Gap for Value-Based Care

According to the Centers for Medicare & Medicaid Services (CMS), value-based care focuses on the quality and performance of a health care providers’ medical services, making the patient’s experience the forefront of how they receive care.¹ Recently seen as an alternative to fee-for-service clinical care—which requires patients or their insurance plans to pay for each bit of medical care they receive—several providers and health companies have explored ideas regarding value-based care.

XiFin is a health care information technology company that assists health care entities in navigating a dynamic and evolving industry. More specifically, utilizing its technology to partner with pharmacists and help improve their bottom line, XiFin delved into the pharmacy market in 2021 after it acquired OmniSYS.²

On a recent episode of Over the Counter, Drug Topics sat down with David Pope, PharmD, Chief Pharmacy Officer at XiFin, and discussed value-based care in the pharmacy profession and how his company is working with 2 out of every 3 pharmacies in the country.

David Pope, PharmD, Chief Pharmacy Officer at XiFin | image credit: XiFin

Stay tuned for more content from our interview with Pope covering multiple topics within value-based care, including where pharmacy benefit managers come into play and how pharmacists may be the best providers to facilitate this type of care.

Drug Topics: Can you start by giving us a summary of how XiFin serves pharmacies across the country?

David Pope: We serve 2 out of every 3 pharmacies out there today, whether it be in the hospital space, retail, all the way from the single-store independent, all the way to the largest of organizations out there, specialty and beyond. We serve to enable pharmacies to be able to operate at the fullest extent of their license and capabilities. We help them to serve their patients by offering clinical services, by offering medical billing, and revenue cycle management services. Many of these pharmacies use us today for billing medical claims, such as an immunization to Medicare, as an example to that, or an office visit to a commercial plan for test-to-treat. [There’s] a lot of things that we do there. We also have a revenue cycle management pathway and billing for that, allowing pharmacists to be able to document within workflow, all connected within their NCPDP pathway, as well as beyond.

We also have other areas such as patient communications. As you can imagine, there's so much to communicate with a patient. If you're going to offer those clinical services, we need to communicate them with them. If I were to summarize, we make it easy to be a pharmacist seeking to provide clinical services to their patients and medical services. And I would say in addition to that, we also make it easy to be a patient seeking services at a pharmacy in that regard. We're excited about that; excited about the future of pharmacy and how pharmacy has really been adopting this in mass scale at this point, offering those clinical services, which was such a great need in today's environment.

READ MORE: Accreditation and Value-Based Care: Leveraging Operational Excellence and Clinical Services for Patients and Your Pharmacy

Drug Topics: What is value-based care and how would it come into play for pharmacies and their employees?

David Pope: Pharmacies today serve a critical role with value-based care. In order to talk about the pharmacy side of this, we ultimately have to start with a plan and a patient, as well as an employer. There's a goal here and that's to provide the best care we possibly can at the lowest cost, so that we can all have those patients and our employees healthy and able to work; and at the same time be able to keep that cost as low as possible. In order to do that, there are many different ways that a plan may decide to try to keep their patients healthy. Of course, everyone plays a role in that, but the plan wants to do that as well. And so for commercial plans and beyond, they may decide to do this on their own, or it may be because of some value-based care initiative that the government has started, such as star ratings would be one area. [That’d] say, “Okay, well, not only do we want value-based care because it's just the right thing to do and we can reduce cost by paying a little on the front end to save a lot on the back end in order to improve care.” There are also times that maybe the government steps in and says, “Hey, here's a program.” And there may be both benefits, and penalties at that point, if these plans don't offer those services and just ultimately don't get to the end state that they want, which is a healthy patient.

Plans can do a variety of different things in order to make that happen. Pharmacies stand in the gap right in so many ways. There may not be a red light in many of these towns, but there's often a pharmacy there. What greater way to be able to affect patient care than face to face using a pharmacist who's able to assess, coordinate, and provide service to these patients? [It’s] documented and communicated back to the plan, communicated back to [a patient’s] primary care provider. And that would be for things like gaps in care, for a patient who has a certain disease state and needs a medication, or perhaps has a disease state where adherence…really matters. And so again, how do we drive those adherence types? Those are just some things, but certainly that is expanding. Pharmacy stands in the gap and so many plans are choosing to partner with pharmacies—again, both large and small—to be able to offer those services and hopefully cover these gaps.

READ MORE: Value-Based Care Models Can Help Pharmacies Improve Operations

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References

1. Value-Based Care. CMS. 2024. Accessed October 14, 2024. https://www.cms.gov/priorities/innovation/key-concepts/value-based-care

2. XiFin expands into pharmacy market with acquisition of omniSYS. XiFin Pharmacy Solutions. December 14, 2021. Accessed October 14, 2024. https://pharmacy.xifin.com/news-and-events/press-release/xifin-xifin-pharmacy-solutions-press-release/