The Untapped Potential of Pharmacy Interoperability for Payers

By Brian Dwyer, Business Strategy Lead  By Brian Eidex, Senior Consultant

Introduction: What Is Pharmacy Interoperability?

Pharmacy interoperability refers to the seamless exchange of information across pharmacies, payers, providers and other stakeholders in the healthcare ecosystem. This concept is critical for improving healthcare delivery by enabling better care coordination, medication management and health outcomes. Pharmacy interoperability allows pharmacists to access patient health information, share data with other care providers and payers and collaborate more effectively within the broader healthcare landscape. For payers, such interoperability offers significant opportunities to enhance care quality, reduce costs and improve patient satisfaction.

The Growing Role of Pharmacists in Healthcare Delivery

As the healthcare landscape evolves, recognition of the critical role pharmacists play in patient care beyond the safe dispensing of medications is widening. With a shortage of primary care physicians, particularly in rural areas, pharmacists are stepping in to fill the gap by providing direct patient care services. A recent report from Surescripts highlights pharmacists’ increasing involvement in ePrescribing and medication management, further emphasizing their role as care providers (Source: Surescripts Data Shows Growing Opportunity to Expand the Role of Pharmacists).

Regional payers are particularly focused on leveraging pharmacists as part of their care teams. For example, with the closure of Walmart's health clinics, a call is growing for Walmart pharmacists to absorb some of that care demand. Payers are recognizing that community pharmacists, who see patients frequently for many reasons including medication management, are well positioned to provide care services that complement primary care providers.

The Expanding Role of Pharmacists in Improving Health Plan Performance and Access to Care

The expanded involvement of pharmacists directly impacts important quality and performance measurements on which health plans are evaluated, including HEDIS (Healthcare Effectiveness Data and Information Set) measures, Medicare Advantage Star Ratings, Quality Rating System (QRS) scores, CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys, and value-based care metrics. These metrics are not only critical for ensuring high-quality care but also tied to financial incentives, regulatory compliance and overall market competitiveness for health plans.

By involving pharmacists in care teams health plans can provide a broader network of accessible care providers, which is crucial in underserved areas or for patients with complex medication needs. Health plans could meet network adequacy requirements more effectively and ensure patients receive continuous care even if they don't have a primary care provider.

Impact on Key Health Plan Metrics

HEDIS Measures

• Medication adherence rates: Pharmacists can help improve medication adherence by providing counseling, reminders and follow-up care.
• Chronic condition management: Pharmacists are well-positioned to manage chronic conditions like diabetes and hypertension through medication adjustments and patient education.
• Immunization rates: Pharmacists can administer vaccines, improving the plan's performance on immunization measures.
• Medication reconciliation post-discharge: Ensuring correct medication use post-discharge helps reduce hospital readmissions, a key HEDIS metric.

Better HEDIS performance can lead to higher reimbursement rates, improved plan rankings and greater attractiveness to potential members.

Star Ratings (Medicare Advantage)

• Pharmacists can directly improve medication-related measures (e.g., adherence, medication therapy management) and enhance patient satisfaction by providing accessible and effective care.
• Health outcomes: Pharmacist involvement in chronic disease management could lead to better overall patient outcomes.

Improved Star Ratings increase reimbursement from the Centers for Medicare and Medicaid Services and make a plan more attractive in the competitive Medicare Advantage market.

Quality Rating System (QRS)

• The integration of pharmacists into care teams can improve access to care, preventive care measures and management of chronic conditions — all important for QRS scores, which evaluate health plans in the health insurance marketplace.

Higher QRS scores improve a plan’s reputation and attractiveness, potentially increasing enrollment.

CAHPS Scores

• Access to care ratings and care coordination scores can improve as pharmacists provide easier and more immediate care, especially for patients who face barriers to primary care access.
• Overall health care quality ratings could rise with improved care coordination through pharmacist intervention.

Higher CAHPS scores can lead to better Star Ratings and patient retention as they indicate a higher quality of patient experience.

Value-Based Care Metrics

• Pharmacist interventions can reduce hospital readmissions, lower overall healthcare costs and improve population health management — critical metrics in value-based care models.

By reducing costs and improving outcomes, health plans can better succeed in value-based payment models, improving financial sustainability and care quality.

Network Adequacy

• Pharmacists can help health plans meet network adequacy requirements, particularly in areas with a shortage of primary care providers. This is important for regulatory compliance and member satisfaction.

Utilization Metrics

• Emergency department utilization rates and hospital admissions could be reduced through pharmacist-driven medication management and preventive care.
• Appropriate use of medications ensures that patients receive the correct medication, reducing costs associated with improper medication use.

Improved utilization metrics help plans reduce costs, meet regulatory standards and improve patient outcomes.

Overall Impact on Health Plans

• Reimbursement: Improving metrics like HEDIS, Star Ratings, QRS and CAHPS scores directly affects reimbursement from programs such as Medicare Advantage.
• Market position: Stronger performance in these metrics makes a health plan more competitive, increasing its attractiveness to potential members and improving enrollment rates.
• Regulatory compliance: Expanding pharmacists' roles helps health plans meet regulatory requirements more effectively, particularly in network adequacy and access to care.

Payer Strategies for Leveraging Pharmacy Interoperability

For payers, incorporating pharmacists into care teams offers several strategic advantages.

• Improved access to care: Pharmacists can serve as accessible healthcare providers, especially in underserved areas. They can perform such clinical services as chronic disease management, medication therapy management and immunization services. By integrating pharmacists into care teams, payers can ensure better access to care, particularly for patients who may not have regular access to a primary care provider.
• Enhanced coordination and continuity of care: Interoperability allows better coordination between pharmacists and payers, especially around finite programs. For example, health plans can use HL7/NCPDP Pharmacist eCarePlan for care coordination and other National Council for Prescription Drug Programs (NCPDP) transactions to reimburse pharmacists for their services, which can help improve patient engagement and quality ratings.
• Reimbursement models and claims processing: Payers must establish reimbursement models that make sense to both payers and pharmacists. For instance, the state of Washington has a rule requiring pharmacists be reimbursed at the same level as other providers for the same services. This equitable reimbursement approach encourages pharmacists to take on a broader role in patient care, which can ultimately lead to better patient outcomes and lower overall healthcare costs.

Real-World Examples and Collaborative Initiatives

The Sequoia Project's new pharmacy workgroup, in collaboration with Surescripts, is one example of an initiative in which payers should consider actively participating. This joint initiative aims to standardize data exchange and improve interoperability across pharmacies, payers and providers (Source: Pharmacy Interoperability Takes Center Stage in Joint Initiative Between The Sequoia Project and Surescripts). By participating, payers can stay ahead of the curve and help shape the future of pharmacy interoperability.

Additionally, the Surescripts Care Team Evolution Summit underscored the need for policy changes, payment models that support pharmacists and technology solutions that provide access to all clinical records. Such discussions are critical for payers looking to leverage pharmacy services as part of their broader care delivery strategies.

Future Considerations for Payers

To optimize the use of pharmacy interoperability, payers should consider the following actions.

• Identify gaps in care: Payers should examine their patient populations to identify gaps in care that pharmacists could help fill. This could include missing vaccination programs for specific patient groups or chronic disease management for patients with vascular conditions.
• Engage in collaborative initiatives: Participation in such collaborative workgroups as the Sequoia Pharmacy WG or the NCPDP Health Plan Subcommittee can help payers stay informed about the latest trends and standards in pharmacy interoperability.
• Support technology integration: Investing in technology enabling pharmacists to access and share patient information seamlessly is critical. The NCPDP Pharmacist eCarePlan and other digital tools should be leveraged to enhance care coordination and improve health outcomes.
• Reassess reimbursement models: To support pharmacists' expanded roles, payers must develop reimbursement models that recognize pharmacists as valuable members of the care team. This could include compensating pharmacists for clinical services such as medication management, chronic disease monitoring and patient education.
• Focus on quality and outcomes: By strategically utilizing pharmacists, payers can potentially improve their quality ratings, patient satisfaction scores and overall health outcomes. This is particularly relevant in value-based care models, where quality and outcomes directly impact financial performance.

Conclusion

Pharmacy interoperability is a critical component of modern healthcare that offers substantial benefits to payers, providers and patients alike. By embracing the role of pharmacists as care providers, payers can enhance care delivery, improve patient outcomes, reduce costs and thereby positively impact HEDIS measures, Star Ratings and QRS scores. However, achieving true pharmacy interoperability will require ongoing collaboration, investment in technology and development of innovative reimbursement models that support this evolving role of pharmacists in healthcare.

Payers looking to explore how pharmacies can be better leveraged within their care networks should reach out to POCP to set up a time to chat. We can help you navigate current challenges and identify key opportunities for integrating pharmacists into your care teams, improving care coordination, and enhancing quality metrics. Whether you’re grappling with reimbursement models, looking to meet network adequacy requirements, or seeking to improve performance on HEDIS, Star Ratings, or value-based care metrics, our team is here to help. Let’s work together to develop strategies that maximize the role of pharmacists and drive better outcomes for your health plan. Contact us today to start the conversation.