Study Finds Improvements are Needed for Value-based Pharmacy Contracts

Performance-based pharmacy payment models have become more common but the measures are sometimes too high for pharmacies to meet and the incentives may not align well with patient care goals, according to a recent survey published in the Journal of Managed Care and Specialty Pharmacy.

Ben Urick, Pharm.D., Ph.D.

“Performance-based contracts between managed care and pharmacies are here to stay. But the best path forward is increasing collaboration among pharmacists, pharmacy groups, and payers, to better align the design of these models with good patient care and allow for true bonuses,” study author Ben Urick, Pharm.D., Ph.D., assistant professor, Eshelman School of Pharmacy at University of North Carolina, Chapel Hill, North Carolina, said in an interview.

With performance-based contracts, pharmacies are paid a bonus, have payment withheld, or may have penalties assessed based on measured goals.

Performance-based pharmacy payment models have become more common with the purpose is incentivize pharmacy to provide better care, monitoring adherence, Urick said. “There really hasn't been a lot of research exploring those models or trying to get a sense for how or why they work.”

In this study, investigators interviewed 17 different stakeholders, including five pharmacists, seven payers, three quality measure developers and vendors, one academic pharmacist, and one member of a national pharmacy organization. The interviews aimed to determine the features of performance-based pharmacy payment models, goals and impact of the models, challenges and recommendations for improvement.

Investigators identified four major components of these programs: attribution, performance and quality measures, incentive structures, and patient care services.

Most of the incentives used in these models is a lose-lose situation for pharmacies. “In the models, if pharmacies perform well, they lose less than they would if they didn’t perform well. The incentive structure is kind of a quirk of these models,” Urick said. “Additionally, what’s needed by pharmacies to improve patient care is a little bit fuzzy.”

Investigators suggested that these payment models could be improved with better transparency and alignment around incentives and quality care measures. Misaligned incentives can result in complex models, and pharmacists may struggle with that complexity. Additionally, the many stakeholders involved may result in conflicting expectations.

“Whether from a purely financial or form a perspective on patient care, plan sponsors certainly think these payment structure work. Among pharmacists, there’s a great deal of debate and disagreement. Pharmacists say the measures aren’t well linked to actual care quality, and they don't feel like they can control them.”

Urick also suggested these payment programs could be improved with a risk adjustment to make them more fair to pharmacists. “These models do not account for variation in patients’ clinical, demographic, and social characteristics, which we know influences the ability of a pharmacist to provide good care.”

Investigators also identified the need for a data infrastructure with shared platforms to allow for data sharing, a common workflow, and training for pharmacists.

Investigators noted, however, that their study did not assess outcomes or effectiveness of performance-based pharmacy payment models; rather, it aimed to understand the components of these models and the influences to be considered for successful integration.