Pharmacy's Role in Value-Based Care

07/02/2024 Written by: AP Employee Benefits

With healthcare costs continuing to rise, employee out-of-pocket expenses – copayments, coinsurance, and deductibles – are also on the rise due to inflation and shifts in employer-employee cost shares. As a result, more  health plan participants are avoiding or delaying treatment, medications and preventive care measures. As employers look for ways to deter this trend in behavior and keep their employee population healthy, some have adopted a value-based care plan design, where copayments and other out-of-pocket costs are based on the value of the therapy to the individual.

Value-based care plans are based on the assumption that individuals may not understand the importance and long-term benefits of seeking treatment, medication and preventive care and, therefore, do not comply with recommendations from their health care providers, often due to the financial impact of out-of-pocket costs. It is widely believed that lowering out-of-pocket costs to the plan member will yield increased compliance with healthcare professional recommendations, ultimately leading to an overall healthier employee population.

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What is Value-Based Care?

Unlike fee-for-service models, where providers are reimbursed by health plans based on the volume of services provided, value-based care models focus on the quality of patient outcomes. In practice, fee-for-service models incentivized providers to order more diagnostic tests/images and perform more procedures as they were compensated based on volume of services rendered, even though the health of patients may not have necessarily been improved as a result of these billed services. In a value-based care model, coordinated and bundled care encourage improved patient outcomes and care quality, all centered around Accountable Care Organizations (ACOs). Unlike the unbundled procedures of a fee-for-service model, ACOs act as a network of hospitals, physicians, specialists, and other care providers working in a coordinated effort to eliminate unnecessary tests and procedures, reduce risk to the patient, and improve overall patient outcomes.

Ultimately, patients who would benefit most from treatment, medication and care pay less – or nothing at all - for services. This model can be particularly effective for employees with chronic conditions such as diabetes and hypertension, as coordinated care increases  the likelihood of adherence to their medication and treatment plans, reducing the risk of most costly care requirements in the future.  According to the World Health Organization, no other treatment has a more direct impact on patient outcomes than medication adherence. The National Library of Medicine has also reported that about half of all chronic disease patients fail to take their medications as prescribed, contributing to $500 billion in avoidable medical expenses annually.

The Role Pharmacy Plays

Pharmacies are known for their onsite expertise, ease of accessibility and patient-centered care, leaning well toward the opportunity to influence healthcare consumerism and providing positive patient outcomes. Pharmacies continue to bridge the gap between patients and the care they need by connecting at-risk patients with the high-value therapies they need.

Here are some ways that pharmacies can play a role in a value-based care model:
  • Medication Adherence and Management: having onsite experts that help answer patient questions on demand can be a valuable asset. The use of patient time can be optimized so that they can be seen and receive and ask questions about medications in one location. According to the University of Michigan Center for Value-Based Insurance Design, it is estimated that it costs an additional $940 per employee for those who do not adhere to their medications as prescribed.
  • Disease Management: Pharmacists can be a valuable resource when it comes to the education of medication usage for many patients, and help them understand that by adhering to the medications they're prescribed can significantly impact their overall health.
  • Disease Management: Pharmacists can be a valuable resource when it comes to the education of medication usage for many patients, and help them understand that by adhering to the medications they're prescribed can significantly impact their overall health.
  • Preventive Care: Many pharmacies have onsite clinics that are able to assess patients for common conditions and administer medications and immunizations on the spot.
  • Value-based care plans also strive to increase the use of high-value services for all employees and discourage the overutilization of low-value or unproven services. For many plans, pharmacies can be a significant influence in their success. The plan may also be structured in such a way that favors and encourages the use of high-quality, lower-cost providers and facilities, further aiding employees as they navigate the healthcare system.

Value-based care strategies to incentivize the use of higher value treatments and treatment program adherence include:
  • variable copays and deductibles,
  • lowering the employee’s premium and
  • cash or gift incentives

Value-based health plans are one of many plan models that may benefit your health plan. As your organization evaluates strategies to manage the health and welfare of your employee population, reach out to your AssuredPartners team for additional resources and support.

Need more insights? Your local AssuredPartners team can help.

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