3 ways health plans can work more closely with pharmacies: Contributed content

For a variety of reasons, including conflicting direct and indirect remuneration (DIR) benefits, pharmacies and pharmacy health plan managers (PBMs) are not the friendliest friends. There are growing concerns that the business practices of pharmacy managers (PBMs) are not in line with public policy objectives to improve the value of pharmaceutical costs, while organizations such as the National Association of Pharmaceuticals (NCPA) are making a serious push to close the loopholes. which harm small public pharmacies but benefit PBM.

Yet, amid noisy legislative controversy and drama, the need for stronger cooperation between pharmacies and PBMs is becoming clear.

CMS has taken decisive action to step up the push for value-based care. In 2020, the agency doubled the CAHPS Health Plan weight survey indicators, which relate to the experience of members, who now account for nearly 40% of the overall health plan star rating, a threefold increase from just a few years ago. At the same time, indicators related to blood pressure control, readmission planning for all causes and care transitions returned to Star Ratings.

Given that members’ experience with their pharmacists influences perceptions and stellar assessments of health plans, joint relationships between care partners can use small couples therapy.

Why it is important to improve the relationship between pharmacies and health plans

While the concept of “member experience” is somewhat elusive – and the results of CAHPS do not always reflect the quality of care – health plans are under enormous pressure to perform well and provide 5-star care and service. For some plans, anything less than 4.5 stars could damage the payer’s ability to stay operational, given the wider jump in the cost of managing chronic illness and readmission.

But what we do know is that members’ experiences – and what members point out in CAHPS surveys – are influenced by their relationships with everything nurses, not just doctors.

Pharmacy professionals are increasingly working on top of their licenses. They are more likely to receive vaccinations and offer guidance and advice to patients than at any other time in history. In unserved parts of the country, sometimes called “medical deserts,” Americans can interact with their professionals in municipal pharmacies more often than with their regular doctors.

The bottom line: If patients receive exceptional care from their pharmacy, it will ultimately benefit the health plan. If staff or services are reduced in pharmacies to compensate for the return of PBMs, these redundancies affect service. And if the quality of the service deteriorates, it will reduce the perception of members.

To say that a patient with diabetes does not receive their medication on time because they are struggling to get it, his or her outcome may worsen – as well as their perception of their experience.


A health plan and collaborative pharmacy partnerships are better prepared for success.

With that in mind, here are three ways health plans can work more closely with pharmacies to improve members’ experiences – and their stellar ratings:

1. Provide visible value-based arrangements with public pharmacies

Pharmacies are not always aware of domestic policies or pricing decisions made by health plans, such as the amount they will be asked to pay for certain medicines.

But having many visible value-based arrangements and programs with pharmacy networks can do wonders for improving communication in all areas (including discussing initiatives to support high-impact measurement quality improvements).

An American Journal of Managed Care Interview with Joseph A. Albright, Pharmacist, Clinical Pharmacy Program Manager, Blue Cross Blue Shield, North Carolina, highlighted the momentum when plans enter into joint value-based arrangements with health systems. “There are often hostile relationships when you first start when it comes to the payer and the supplier, because we’re used to bumping into each other’s heads,” Albright said. However, Albright also said that his best relationships with doctors are those in which they are clearly involved in decision-making and treated as equal partners. Similarly, value-based programs through direct arrangements with pharmacy networks can foster collaboration and efficiency.

2. Use an integrated care management platform to more effectively coordinate care and values-based initiatives

When health plans, PBMs, and community pharmacies use different technologies to track supply chain management, drug administration, and patient care, it may be difficult to monitor progress-related progress (eg, adherence to vaccines). against the flu, satisfaction with the medication plan) and engage members in a coordinated way. The use of an integrated clinical care management platform can help optimize drug use, monitor care management, reduce avoidable healthcare costs, and improve accountability for compliance and quality.

3. Look for the easiest reciprocal opportunities to improve star ratings

Health plans regularly analyze data sources such as CAHPS data and their own prescription claims data to find the most obvious opportunities to improve performance. But they do not always communicate their findings through these in-depth analytical exercises to their care partners. This is a mistake, as there are many opportunities to work with fruit so that pharmacies can work with health plans to improve care and service. Once value-based intervention arrangements have been put in place through integrated clinical platforms, as discussed above, the platform exists for a very visible focus on pharmacy-specific mutual opportunities for improvement.

Without having to guess, pharmacists can do what they do best – solve problems. For example, if compliance measures for Part D are lower than expected, pharmacy partners may consider simple “fixes”, such as introducing a new web chat or auto-charging service that can help patients get the necessary medicines on time and make it easier to help with this measure “Getting a need for recipes” too!

Working together to achieve common goals will become more important among all health stakeholders, as value-based care is needed throughout the country.

When health plans and pharmacies accept collaborative relationships instead of oppositions, both are more likely to succeed with the CMS Star Rating Program and other quality initiatives, and this success translates into more members who are happy with their care and stay recorded in your plan.

Anna Hall, PharmD, BCACP is a director of service quality at Transaction Data Systems, a pharmaceutical technology and analysis company.

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