Improving the evidence base for performance-based pharmacy payment models

Once rare, value-based models for pharmacy practice are now commonplace. More than 42 million patients enrolled in performance-based payment (PBPPMs) managed through one vendor alone.1Pharmacy quality solutions. Pharmacy solutions Web site.https://www.pharmacyquality.com/Date accessed: September 13, 2021Google Scholar Spanning Medicare, Medicaid, and commercial plans, PBPPMs use performance measures to modify payments. Despite the proliferation of recent years, research evaluating impact these is scarce optimal model design remains poorly understood. At highest level, there have been few published evaluations PBPPMs. most specific insufficient understanding relationship among elements such as patient assignment, measure selection, incentive on success. Across all levels, needed improve PBPPMs, researchers economic, social, administrative sciences can play an important role continue evolve. Theory suggests that structure, selection implementation, workflow personnel, patient-level organization-level factors influence success a PBPPM.2Harrington A, Malone D, Doucette W, et al. A conceptual framework evaluation community pay-for-performance programs. J. Am. Pharm. Assoc. (2003). 6 July 2021.https://doi.org/10.1016/j.japh.2021.06.022.Google Scholar,3Urick B. Richard C. Pathak S. Livet M. Jackson Structure implementation environment models.J Manag Care Spec 2020; 26: S15Google Although identified important, large-scale program explore contribution One effort best described literature PBPPM implemented by Community North Carolina (CCNC) 2015. Funded $15 grant from Center Medicare Medicaid Innovation, project demonstrated feasibility using outcomes evaluate performance.4Urick B.Y. Ferreri S.P. Shasky Pfeiffenberger T.M. Trygstad T. Farley J.F. Lessons learned global outcome assess performance.J 2018; 24: 1278-1283PubMed Google In addition, improved medication adherence but had no meaningful health care spending or use.5Urick T.K. Patient implementing enhanced services network.J Am Pharm Assoc 60: 843-852.e15Abstract Full Text PDF PubMed Scopus (1) Reasons lack broad-based varied mostly speculative, include consistent well-defined weak linkage between pharmacists’ improvement efforts chosen incentivize it.6Renfro C.P. Urick Mansour M.A. characteristics correlating network.J. 2019; 59: 275-279Abstract (6) Scholar,7Urick Bhosle pharmacies participating 718-722PubMed Out this was formed CPESN USA, clinically integrated network helped foster similar with broad range payers across country.8CPESN siteCPESN USA.https://www.cpesn.com/Date May 29, 2019Google before USA sponsored Wellmark Blue Cross Shield Iowa. This uses measures, including process depression screening total cost care, determine bonuses paid insurer.9Al-Khatib A. Andreski Pudlo W.R. An pharmacies’ actions under payment.J 899-905.e2Abstract recently found correlation participation lower significant differences hospitalization rates emergency department visits.10Doucette DeVolder R. Heggen Evaluation financial pharmacies.J 2021; 27: 1198-1208PubMed Supplementing evidence, early results positive Kroger glycosylated hemoglobin (A1c) values Humana reported at national conferences podcast.11Pharmacy corner.https://www.buzzsprout.com/726174/8686173-improving-patient-outcomes-with-humana-s-expanded-a1c-programGoogle evidence generated CCNC demonstrates value academic design, hope other follow lead present publicly. addition overall has explored. For example, attribution assigning vary widely The required fill least 80% their chronic medications single pharmacy,4Urick whereas attributes based majority-of-fills rule.10Doucette variation comprise basis performance-modified reimbursement also different rules attribution. developed pharmacy-level endorsed Quality Alliance arbitrary 51%-of-fills rule inconsistency creates confusion, profession would benefit greatly more evidence-based set models. There little sets be included Optimal choice likely varies payer population should mix measures.12Conrad D.A. theory incentives application care.Health Serv Res. 2015; 50: 2057-2089Crossref (68) focus too strongly may experience assignment scores. if serves exceptionally poor high social risk, cause perform regardless actual care. intermediate A1c control beginning used some PBPPMs11Pharmacy serve reliable indicators broader measures. Finally, magnitude direction substantial models, designs As reported, direct indirect remuneration mechanisms Part D plan sponsors managers often lose-lose where defined smaller losses instead bonus.13Urick Hughes T.D. Design effect 306-315PubMed loss aversion increases potency negative incentives, lost revenue frustration disengagement providers.12Conrad Much witnessed media floor debate American Pharmacists Association House Delegates. Likewise, small survey dissatisfaction confusion related PBPPMs.13Urick Compounding current rate setting practices frequently result below acquire product.14Murry L. Gerleman Urmie Third-party generic prescription drugs: prevalence below-cost maximum allowable cost-based reimbursement.J. 58: 421-425Abstract (0) potential common loss-only quite rare understudied. work uncoupling drug products. Value-based remain dominant pharmacies. Some successful improving reducing spending, test populations. regarding needed, goal creating maximize value. Benjamin Y. Urick, PharmD, PhD, Assistant Professor, UNC Eshelman School Pharmacy, Chapel Hill, NC; E-mail: [email protected]