Q&A: Why Value-Based Care Can Lead to Increased Revenue in the Pharmacy

In part 3 of his interview with Drug Topics, David Pope, PharmD, Chief Pharmacy Officer at XiFin, discussed how pharmacies can reap the benefits of providing value-based care amidst declining reimbursements stemming from pharmacy benefit manager (PBM) tactics. From a time where pharmacists were not overworked or overstaffed to today’s landscape of declining reimbursements, Pope explored where value-based care falls in between ongoing industry challenges.

“There was a time when we all considered [value-based care to be] the right thing to do because the margins on the medications were sufficient to be able to cover that. And now that's not the case, as most will say and agree with. Pharmacies being able to provide that level of service [are] now challenged because of the reimbursement.”

Touching on the association between pharmacy reimbursement and value-based care, Pope went into depth about how PBMs are intertwined within these models. Read on to learn more about value-based care models from the perspective of someone working closely in the pharmacy solutions industry with other pharmacists from around the country.

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

Stay tuned for a full-length version of our discussion with Pope, which will be available on all Over the Counter podcast platforms.

Drug Topics: When discussing the money behind pharmaceutical services, it would be difficult not to mention the role of PBMs within the supply chain. How or where do PBMs come into play regarding value-based care? Would PBMs and their affiliated insurers support value-based pharmacy models?

David Pope: From a value-based care perspective, we must be clear in what and how we define the value-based care opportunities. Right now, so far, we've discussed value-based care being a gap, something that you're not taking, or perhaps a test that you haven't received, such as an A1c test, colorectal cancer screening test. Those are gaps. That is different than what we've seen. There's some discussion that's out there that says perhaps medications in general should also be in a value-based care opportunity pathway. Perhaps the payment process for prescription drugs could be there. I won't touch that one. I think that one's out there, but I don't know that it's getting a whole lot of traction today. But certainly, in terms of the gap in care, everyone sees it, and so certainly the plan is the one that is ultimately responsible for that.

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

The pharmacy benefit managers are an arm of that. But they're not necessarily always responsible for that. For star ratings, they played a key role in that. Again, they're probably more of the stick than the carrot these days, as much has been discussed, but certainly they have played a role in value-based care, trying to say this patient is not adherent; let me tell you who they are. And then, of course, pharmacy reimbursement is now based off of that. We've seen the ripple of that and the effect of that across pharmacy. And of course, XiFin stands in the gap as well, along with the rest of pharmacy in singing that same song that everyone certainly plays a role there in value-based care.

We believe that the medical benefit; they're the ones who are charged more than anything else. The plan itself is the one who is charged with ultimately creating a pathway for pharmacies, for physicians, for everyone to be able to play a role in value-based care. It's not just pharmacy, not just the physician, not just the lab, it's all of us collectively. Therefore, again, the pharmacy benefit manager is a small part of that and certainly plays a role, but it's a small part of a bigger picture.

Drug Topics: As of late, PBMs have faced immense scrutiny because of their practices within the supply chain, putting smaller, independent pharmacies out of business. Do you believe a value-based pharmacy model is a viable option for individuals owning or operating an independent pharmacy?

David Pope: I think of several friends who've started up the cost-plus model that are out there. My friends in Pennsylvania and beyond [have] just done incredible work there. I would say that pharmacy has always acted in a value-based care model way. You mentioned independent pharmacy. I was in independent pharmacy as well, and I worked there for about a decade. I saw every day firsthand how we were very much involved and intricately involved in the life of our patients. I was a diabetes educator, for example. Every single month, we would have a diabetes class that would teach our patients how to eat. We’d bring in nutritionists, we’d bring in exercise folks as well, to be able to train and help and assist. We would ask them for their A1c. If they didn't know it offhand, we would call their physician.

This idea of value-based care is something that is just, from my perspective, how independent pharmacy, and pharmacy as a whole, just does business already. I think this is a great opportunity for pharmacy to be able to monetize that, to be able to support that, and ultimately just be reimbursed for that time. There was a time when we all considered this is just the right thing to do because the margins on the medications were sufficient to be able to cover that. And now that's not the case, as most will say and agree with. Pharmacies being able to provide that level of service is now challenged because of the reimbursement. Our hope is that there is a reimbursable model for that, and we're seeing that. It's great to see just a real breakout right now in terms of value-based care and fee-for-service opportunities. What I used to do back in the day in Georgia, again, is being reimbursed by plans and recognized by plans and providers on a consistent basis—the likes that we haven't seen before.

READ MORE: Q&A: Pharmacy’s Evolving Relationship with Value-Based Care

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