Are the New Payment Models Increasing Revenue for Pharmacies?

March 22, 2016

Are the New Payment Models Increasing Revenue for Pharmacies

Healthcare reform has initiated new care delivery and payment models, especially the shift from Fee-for-service (FFS) to Value-based reimbursement/incentives. Against this scenario how do pharmacies fare? Have their revenues declined or have the new payment models with the new rules and regulations pushed the revenues and provided for a more efficient and effective Revenue Cycle management (RCM) process?

It is the underlying mission of pharmacies to see that patients receive the right medications, in the right doses & at the right time. Facilitating this to ensure high quality results that are demanded by patients, providers and payers under the new payment & delivery models, like the Accountable Care Organizations (ACOs) and value based purchasing, makes it a bit crucial for pharmacies to become more efficient to effect enhanced revenues. Moreover, with Medicare promoting services to which pharmacists are now also included in the ambit of healthcare providers, and seen beyond dispensing prescriptions and now besides dispensing but also providing patient care services, will definitely lead to an increase in revenues and thereby a much more healthy pharmacy Revenue Cycle Management (RCM) Process.

Different kinds of pharmacy models emerged enable outcome-associated payment models that streamline workflow eventually contributing to increased revenue.

  • A complete pharmacy model that is owned and/or controlled by the System/IDN/IHN/ACO, including a physical community pharmacy outlet, mail-service pharmacy, specialty pharmacy, home infusion, infusion suites and even patient services.
  • A medication therapy management (MTM) service that could be owned by the System/IDN/IHN/ACO, which can dispense and utilize within a preferred network of pharmacies. Research had shown that the Dispensing prescription model had shown approximately 50 percent profit when compared to MTM services because of various challenges that existed with the MTM services, the major challenge being the episodic cases as against the regular dispensing activity. But with greater commitment, this is changing.
  • Poly-pharmacy outsourced by the System/IDN/IHN/ACO to a third party that has and includes retail, mail-service pharmacy, specialty pharmacy, and patient services.
  • Chronic care management services (CCM), promoted by Medicare, can now also be fulfilled by the provider or performed by an offsite subcontractor. So a pharmacy could subcontract with a group practice to manage all of the chronic care needs of its patients. Given this collaborative practice agreement, the pharmacy could make a larger impact on patient care and help generate revenue for the group practice. But it should be noted that, due to the Medicare compliance requirements, chronic care management services are best handled using a team approach.

However, the initial three models are more prevalent for specialty drugs. Moreover, the Time to Fill, Medical Possession Ratio (MPR) PR and Time on Therapy, also impact the overall cost of care, quality of care and patient outcomes, especially for specialty drugs.

The Value Based Incentive Models that can be integrated into the pharmacists community which will not only provide incentives to better revenue but will have a major and positive impact on the healthcare of the population. So there is definitely a positive outlook with respect to the new payment models bringing in increased revenues by improving pharmacy billing enhancing their Revenue Cycle management (RCM) process.


Category : Revenue Cycle Management