Putting Pharmacies First

Pharmacy First consistently seeks out ways for our pharmacies to lower their DIR fees, while also being able to improve their patient’s quality of life. We have seen how hard the pharmacies within our network are working with their patients, so we wanted to start highlighting these pharmacies in our Quarterly Blog! In these, we hope to congratulate a high performing pharmacy who has stood out amongst the crowd; while also sharing their knowledge and experience on what has worked for them to improve their own independent pharmacy.

Currently, the healthcare system is trending towards a proliferation of value-based purchasing arrangements in which payment for services is tied not just to a set fee per service, but also to an incentive for providers who can demonstrate improvements in patient care. To proactively take on this trend, Pharmacy First has worked with Pharmacy Quality Solutions (PQS) to allow pharmacies within our network to obtain EQuIPP® at a vastly discounted rate! EQuIPP® is an innovative performance information management platform that was designed to help pharmacists thrive in a value-based, quality-focused environment.

Pharmacy of the Quarter

This quarter we are highlighting an independent pharmacy from Opelousas, Louisiana, who has utilized EQuIPP® services and shown us just how quickly a pharmacy is able to boost their overall Star Rating from a 3, all the way to a 5 Star Rating in just a matter of months! We had the pleasure of speaking with Germaine from Germ’s Thrift Clinic Pharmacy, as she shares her thoughts on EQuIPP® services.


Pharmacy First:

First and foremost, what made you want to obtain EQuIPP® originally?


I previously had a supervisor who assisted me with OutcomesMTM’s at first. After this, they advised me to reach out to my PSAO at the time and log in to EQuIPP® to identify outliers.  It was not until I switched PSAO’s to Pharmacy First that I gained the knowledge to use the dashboard properly.


Pharmacy First:

How did you begin to incorporate EQuIPP® into your daily workflow?


Unfortunately, it did take me a couple of years to realize that I needed to focus on more than just outliers.  Once I turned my focus to the Analyze Performance tab, things started falling into place. We started to run reports weekly for each insurance that appeared in the Analyze Performance tabs, from there we can see exactly which patients would affect our scores. This helped us save time, so we weren’t dealing with just individuals who affect our scores.


Pharmacy First:

What sort of value has EQuIPP® brought to your business?


EQuIPP® has helped my knowledge tremendously.  Not just the platform itself, but its team members are always willing to help if you have questions.  Remember, people are available, it is not just a platform to visit.  EQuIPP® has also helped me to remain on the lower percentage of what is recouped by PBM’s.


Pharmacy First:

What other programs or services helped your pharmacy to improve so rapidly, and how did they do so?


I have been using Medicine-On-Time for adherence packaging for the patients who show up as outliers. Their team has gone out of their way to help me with my scores. My patients do not fall through any cracks!


Thank you for taking the initiative to find out what has made this pharmacy successful in such a short amount of time. If you would like to sign up for EQuIPP® services, have further questions about the program, or simply just need help managing the program for your business, please reach out to our pharmacist on staff: dalton.thompson@pharmacyfirst.com 

Managing Profit & Loss: The Importance of Data in Reducing DIR Fees

For independent pharmacy owners, managing Direct and Indirect Remuneration (DIR) fees on Medicare Part D claims can feel like a guessing game with potentially serious implications. DIR fees are assessed and “clawed back” weeks or even months after adjudication at the point of sale. The fee amounts can vary significantly – given that they are tied to performance-based contracting – and in some cases, they result in a net loss for the pharmacy. The fees are often lumped together, which makes it more difficult and time-consuming for pharmacies to analyze which claims are subject to DIR clawbacks.

The National Community Pharmacists Association (NCPA) reported that two-thirds of the pharmacies surveyed said PBMs “provided no information on the amount or timing of DIR fees.” Furthermore, nearly nine in 10 said DIR fees were “significantly affecting their pharmacy’s ability to provide care and stay in business.” This lack of transparency, coupled with the delayed (post-adjudication) nature of DIR fees, creates obstacles that can be challenging for pharmacies to overcome on their own.

For these reasons, it has become essential that pharmacies have a support system in place to decrease the chance of losses from DIR fees. A high-performing Pharmacy Services Administrative Organization (PSAO) will offer the right tools for enhanced performance as well as visibility. But those tools – and the PSAOs that offer them – are not all the same.

When choosing a PSAO partner, look for one that provides multilayered visibility into fees, performance goals and measurements on a user-friendly platform. Armed with the right data-driven insights, independent pharmacies should have the ability to:

  • Access an individual member portal that shows their payers and associated fees
  • Actively monitor performance across multiple payers and check overall scores
  • Narrow down the focus to gauge performance for one specific payer
  • Identify patients who are bringing scores down (“outliers”), so pharmacies can reach out to them and help address issues such as low adherence rates
  • Keep operational efficiency and profitability at a higher level

A great PSAO will provide personalized guidance to ensure you understand how to access – and act on – the data to drive greater profits and fewer losses. Such hands-on, pharmacy-centric guidance should include:

  • A thorough explanation of how to take full advantage of the data
  • Education about what the pharmacies are being measured on regarding DIR fees
  • Visibility into how the entire network is performing to help each member pharmacy benefit from higher scores and lower fees

Additionally, a true PSAO partner will provide a Medication Therapy Management (MTM) platform, which can be used for comprehensive medication reviews (CMRs) with patients. Because CMRs are included in the metrics that determine DIR fees with some major payers, pharmacies that use MTM platforms can check adherence rates and engage lagging patients, even on plans where CMRs are not required – all of which can help lower DIR fees across the board. Adherence check-ins on MTM platforms can have financial incentives for pharmacies as well.

For independent pharmacies, the successful management of DIR fees is a key component of staying profitable and competitive. With the help of a PSAO that is focused on supporting you and your unique financial challenges, you can improve your awareness, understanding and response to DIR fees, for better management and better results.

To learn more about how Pharmacy First can help, contact us.

About the Author

Todd Wormington is the Director, Pharmacy Programs for Pharmacy First and has over 25 years of pharmacy industry experience. His work as a practicing pharmacist helped frame a passion for direct patient care and led to a career focused on the clinical and operational resources required to deliver enhanced pharmacy services in a community-based setting.


Managing and Reducing Pharmacy Audit Risks

The number of audits by Pharmacy Benefit Managers and other third-party payers has steadily increased in recent years, with more than 1,200 Pharmacy Audit Interventions being entered in 2018. Increased levels of interventions can take a growing toll on the time and resources of independent pharmacies, with audits taking upwards of 120 days to complete.

PBMs watch for many different triggers that can lead to an audit, so it’s critical for pharmacies to be aware and anticipate risks.

A high-performing Pharmacy Services Administrative Organization (PSAO) can save pharmacies thousands of dollars in audit expenses and loss of reimbursement, allowing the pharmacies to remain focused on patient care.

For the PSAO, the key is to make pharmacies aware of the many factors that can lead to a third-party audit and help them make proactive adjustments before an audit occurs.

Some common audit triggers include partial dispensation of medication (indicating that stock is too low), plan limits exceeded, clerical errors or missing documentation. PBMs often have different sets of rules about adjudication of certain claims, thus pharmacies need to know what applies to their specific claims to avoid mistakes. In addition, many PBMs have implemented their own audit profiles that are specific to a market or even a ZIP code — based on fraudulent prescribing behaviors or a high incidence of issues with controlled substances, for example — that can be highly variable and difficult to track.

A service-oriented PSAO will collaborate with both the PBM and the pharmacy to identify audit risks and prevent or reduce the number of audits, by:

  • working directly with PBMs to determine their specific audit triggers
  • analyzing transactional point-of-sale data regarding claims from pharmacies to pinpoint risk possibilities
  • providing pharmacies with real-time data, education and awareness
  • monitoring the pharmacies’ operations to look for triggers, risky activities or lax policies
  • advising and proactively assisting pharmacies in avoiding those triggers and making positive operational changes as needed

Taking these crucial steps to minimize audit risks will help independent pharmacies avoid unnecessary expenditures of time and money, so they can focus on remaining profitable, competitive and patient-centric. With the help of a PSAO that knows how to support you and the many challenges of managing an independent pharmacy, you can improve your awareness, understanding and response to audit risks, for better results in your operational strategy and with your bottom line.


To learn more about how Pharmacy First can help with minimizing your audit risks, contact us.


About the Author

With more than 13 years in the pharmacy industry, Ashley Otte is the Director of Reconciliation for Pharmacy First. She manages a team specializing in financial oversight of independent pharmacies. Her expertise also includes all aspects of working with PBMs and ensuring an excellent customer experience.


PSAOs and Independent Pharmacies: Collaboration for Better Service and Better Business

As a leading Pharmacy Services Administrative Organization (PSAO), our goal at Pharmacy First is, first and foremost, to support independent pharmacists in all aspects of their businesses. As such, our most recent white paper, “Partnerships for Better Business,” can serve as an excellent resource for pharmacies in search of a high-functioning PSAO to address their unique issues and help them stay competitive – especially when it comes to customer service.

In this increasingly complex healthcare market, independent pharmacies face numerous operational and financial challenges. But equally critical (and complicated) is the relationship with the customer. Community pharmacists need quality time with their customers to provide the excellent service they expect, with the goal of fostering loyalty, retaining the customer base, and ultimately growing the business.

So how does an independent pharmacist balance the many tasks of running a business on the back end with the need to provide even deeper levels of customer care on the front end? That’s where a PSAO partner comes in.


Excellent patient care and service lead to improved outcomes

Independently owned pharmacies have long maintained a reputation for locally rooted, personal service that couldn’t be matched by national chains. However, even large pharmacies have begun to put a premium on face-to-face time for better patient experiences. Today’s community pharmacists no longer feel they have the market cornered on the ability to offer plenty of interaction and personalized attention.

Yet, this aspect of the business is an operational necessity for customer retention and growth. According to a study published in Pharmacy Times, high-risk patients see their pharmacist an average of 35 times a year, compared with four visits to their primary care physician and nine to specialists. In addition, independent pharmacies often provide services that go beyond dispensing prescriptions, such as immunizations, blood pressure monitoring, and medication therapy management and adherence. Pharmacists must capitalize on these opportunities to shape the health of their patients and keep relationships strong.

Ideally, independent pharmacies will find a partner in a PSAO that serves as an advocate, supports the business and handles administrative tasks, so pharmacists can focus on communicating with the customer. This helps them offer a higher level of care and improved customer service, which leads to better patient outcomes and, of course, a better business.


PSAOs give pharmacies the time they need for customers

What distinct services will a PSAO offer that allow community pharmacies a greater emphasis on customer satisfaction? Our white paper examines several key specifics of the link between PSAOs and their ability to help independent pharmacies cater to their customers:

  • A service-focused PSAO will handle time-consuming business functions such as claims reconciliation and credentialing, leaving pharmacists free to nurture their patient relationships and make a bigger impact on community health;
  • A PSAO’s expertise in third-party contracting helps protect independent pharmacists and enhance their ability to compete, with more favorable reimbursement terms and conditions;
  • An effective PSAO uses data-based performance management platforms to offer solutions, drive clinical improvement and boost quality;
  • The right PSAO will support the independence and autonomy that community pharmacies want to maintain.

Not all PSAOs are created equal, so we are here to help independent pharmacists recognize how a true PSAO partner demonstrates its value. Read the white paper in its entirety, or contact us to learn how our team can support your better business by giving you the freedom to stay focused. In order to take the best possible care of your customers, you need us taking care of you.


About the Author

With more than 18 years in the pharmacy industry, Candace Sullivan is the Vice President of Customer Experience for Pharmacy First. Candace’s expertise, which ranges from assisting pharmacists behind the pharmacy counter to ensuring patients’ insurance needs are met, provides valuable perspective in her efforts to provide top-notch service to our PSAO network members.

Six Questions to Answer When Searching for a PSAO Partner

Independent pharmacy owners: When it comes to finding support for your business and operations, the smartest advice I can offer is this: Look for a partner, not just a vendor.

What is the difference? For starters, vendors are primarily driven to sell as much as they can regardless of what is best for your unique business. Partners, on the other hand, are driven to help you succeed.

A Pharmacy Services Administrative Organization (PSAO) that strives to exceed expectations by focusing on your success provides hands-on, quality-focused, results-driven attention from day one. The way the customer service team for a PSAO approaches onboarding for new members is an important reflection on the PSAO’s service philosophy. If they are truly committed to serving as your partner, they will offer you an interactive introductory experience that involves your input on specific market needs. Through a personalized, “white-glove” approach to onboarding, they will take time to guide you through important business decisions at the point of enrollment process. Their most fundamental goal should be to illuminate the best path forward to achieving your specific business goals and operational objectives.

Here are six questions to ask yourself before choosing a PSAO or switching to a new PSAO:

  1. Can they deliver more favorable third-party contracts? If they consider themselves your partner (not just a vendor), a PSAO strives to support your top line revenue by delivering the best possible terms and conditions to maximize your reimbursements on every contract. They will also assist you with procuring all the contracts you need, even those that aren’t available directly through the PSAO’s own network.
  2. Will they provide hassle-free claims reconciliation solutions? A partner also supports your bottom line in every way they can, including a robust system for claims reconciliation that ensures you receive all monies due on your claims.
  3. Do they consider it their mission to relieve you of administrative burdens while also providing a full suite of revenue-enhancing opportunities? Going far beyond the role of a vendor, a PSAO partner provides the same back-office functions that are managed by corporate office staff at national chains.
  4. Are they committed to supporting your pharmacy in ways that maximize benefits to you? A partner brings expertise to effectively manage and grow your business while minimizing disruption to your operations.
  5. Will they respect your independent business values and fully support your autonomy as the business owner? A partner upholds your right to choose your own wholesalers and other suppliers, rather than attempting to tie your purchasing decisions to their preferred vendors.
  6. Do they merely provide information, or do they provide actionable insights and solutions? A partner analyzes meaningful data, gleaned from performance measurements and quality insights, to help you enhance your strengths and pinpoint areas for improvement.

If you can answer yes to every one of those six questions, you’ve found a true PSAO partner – one that will put your needs first and offer the smart business solutions you need in today’s complex, evolving market. At Pharmacy First, we pride ourselves on supporting the success of thousands of independent pharmacies. Our work ultimately supports our members, provides new opportunities and bridges operational gaps to ensure consumers have access to pharmacy services and products with the personalized touch that only independent pharmacies can deliver.

With the superior support you receive from a PSAO partner, you are free to do what you love: give your customers excellent service, consistently meeting their needs and fostering their loyalty. To learn more about what makes our team your “partners in excellence,” contact us

About the Author

Candace Sullivan is the Vice President of Customer Experience for Pharmacy First, and has more than 18 years in the pharmacy industry. Candace’s experience, which ranges from assisting pharmacists behind the pharmacy counter to ensuring patients’ insurance needs are met, provides valuable perspective in her efforts to provide top-notch service to our PSAO network members.


Getting Ready for 2019 CMS Opioid Claim Edit Requirements

The Centers for Medicare & Medicaid Services (CMS) understands the magnitude of the nation’s opioid epidemic and its impact on communities and recently published a roadmap with a three pronged approach to combating the opioid epidemic:

  • Prevention of new cases of opioid use disorder (OUD)
  • Treatment of patients who have already become dependent on or addicted to opioids
  • Utilization of data from across the country to better target prevention and treatment activities.

The new policies include improved safety edits when opioid prescriptions are dispensed at the pharmacy and drug management programs for patients determined to be at-risk for misuse or abuse of opioids or other frequently abused drugs. CMS’s tailored approach is to help distinct populations of Medicare Part D opioid users, including new and chronic users, those with concurrent medication use and high-risk users.


Claim Level Edits

CMS’s new opioid policies for Medicare drug plans start on January 1, 2019. The new policies include improved safety edits when opioid prescriptions are dispensed at the pharmacy and drug management programs for patients determined to be at-risk.  It is important to note that CMS’s final call letter does not limit the prescribing of opioids but does outline requirements for hard and soft edits during the claims adjudication process.  Examples include:

  • Seven-day supply limit for opioid naïve patients (hard edit)
  • Opioid care coordination edit at 90 morphine milligram equivalent (MME)
  • Optional hard edit at 200 MME or more
  • Concurrent opioid and benzodiazepine use or duplicative long-acting opioid therapy (soft edits)


7-Day Supply Limit Edit

This edit is focused on opioid naïve Medicare Part D patients who have not filled an opioid prescription recently.  They will be limited to a supply of 7 days or less and this edit should not impact patients who already take opioids. Subsequent prescriptions filled during the plan’s review window (generally 60-90 days) will not be subject to the 7 days supply limit.

Overrides may be communicated at point-of sale (POS) with a transaction code or by contacting the plan directly. Patient may receive up to a 7 days supply or request a coverage determination for full days supply as written. If the issue is not resolved at the POS and the prescription cannot be filled as written, including when the full days supply is not dispensed, distribute a copy of the standardized CMS pharmacy notice Medicare Prescription Drug Coverage and Your Rights to the patient.


Opioid Care Coordination at 90 MME Edit

This is a formulary level edit will trigger when a patient’s cumulative MME per day across his/her opioid prescription(s) reaches or exceeds 90 MME. Some plans use this alert only when the patient uses multiple opioid prescribers and/or opioid dispensing pharmacies. If the pharmacist recently consulted with the prescriber and has up to date clinical information (e.g., Prescription Drug Monitoring Program (PDMP) system or other records), additional consultation with the prescriber is not expected.

Provide information to the plan for override if known to the pharmacist that patient has an exclusion (discussed above) or if prescriber has recently been consulted and the pharmacist has up to date clinical information. Overrides may be communicated at POS.

Pharmacist should consult with the patient’s prescriber to confirm intent and be consistent with current pharmacy practice to verify the prescription and to validate its clinical appropriateness. This is an opportunity for pharmacists to inform the prescriber of other opioid prescribers or increasing amounts of opioids.


Optional Hard Edit at 200 MME or More Edit

Some plans may implement a hard edit when a patient’s cumulative opioid daily dosage reaches 200 MME or more.  Some plans use this alert only when the patient has multiple opioid prescribers and/or opioid dispensing pharmacies.

Provide information to the plan for override if known to the pharmacist that patient has an exclusion (discussed above). Overrides for exclusions from the safety edit may be communicated at POS with a transaction code or by contacting the plan directly


Concurrent Opioid Use Edit

These soft edits will trigger when the patient is taking opioids and benzodiazepines concurrently or is taking multiple long-acting opioids. The pharmacist should conduct additional safety review to determine if the patient’s opioid use is safe and clinically appropriate.

As with all of the edits, record any documentation including the date, time, name of prescriber, and brief note that the prescriber confirmed intent, did not confirm intent, provided information on patient exclusion and override information at the point of sale.  If the issue is not resolved at the POS and the prescription cannot be filled as written, distribute a copy of the standardized CMS pharmacy notice Medicare Prescription Drug Coverage and Your Rights to the patient.

For more information, Pharmacy First members can login to the Member Portal for plan specific requirements or go to CMS’s website: https://www.cms.gov/Medicare/Prescription-Drug-coverage/PrescriptionDrugCovContra/RxUtilization.html


About the Author

Todd Wormington is the Director, Pharmacy Programs for Pharmacy First and has over 25 years of pharmacy industry experience. His work as a practicing pharmacist helped frame a passion for direct patient care and led to a career focused on the clinical and operational resources required to deliver enhanced pharmacy services in a community-based setting.

Only in the Business of Pharmacy…

Within the healthcare delivery engine, community pharmacy has been largely overlooked, often perceived as a dispensary function. Today, nothing could be further from the truth. The pharmacist’s role has evolved to include more patient care services, providing a vital link between the patient and entire healthcare system. While these changes are transformational, pharmacy is not only a profession, it is a business. After all, a community pharmacy is a retail operation just like any other. Except it is not.

There is no other industry that operates quite like pharmacy, and the list of challenges faced by community pharmacy is long and growing.

Access vs. Quality

A fundamental question in the business of pharmacy involves access to patients versus the value of reimbursements received for filling prescriptions. Historically, access to patients has won out over reimbursement to keep patients coming in the door. This may be changing.

For most independent pharmacies, the biggest contribution to revenue comes from dispensing medications. However, reimbursement rates have become so aggressive and margins so thin that access to patients who cost the store money is becoming less desirable. Add the impact of direct and indirect remuneration fees that are assessed sometimes months after the prescription has been filled, and the reimbursement hole gets even deeper.

The problem is that a pharmacy cannot pick and choose which customers to serve. Third party payer contracts are so locked down that a pharmacy cannot refuse to serve a patient due to low reimbursement. In fact, even if the medication dispensed is reimbursed below the pharmacy acquisition cost, the pharmacy must still fill the prescription. Indeed, there is no other industry like pharmacy, and there is no other buyer-and-seller marketplace in the world where the buyer always wins.

Direct and Indirect Remuneration

Over the past few years, direct and indirect remuneration (DIR) fees have taken center stage over other issues like maximum allowable cost (MAC) pricing and preferred networks. Basically, DIR refers to monies that a Medicare Part D plan or pharmacy benefit manager (PBM) may collect to offset member costs.

Often called Performance Payments or Incentives, there is little to no carrot and mostly just stick involved in these arrangements. Calculation of DIR fees varies widely but is mostly based on a generic dispensing rate (GDR), although some include the Centers for Medicare and Medicaid Services star ratings, formulary compliance, or other parameters. In most cases there is virtually no possibility of eliminating a DIR clawback – only the possibility of reducing the amount taken. Even then, the DIR will be based on the aggregate behavior of all stores in a network, meaning an individual pharmacy will be subject to the DIR regardless of how well it performs.

For pharmacies, DIR fees are price concessions not adjudicated at the point of sale, so a pharmacy does not know how much will be charged until the fee is collected. This lack of transparency makes it impossible for pharmacy owners and managers to know whether they made or lost money on a script until several months after it was filled. Again, the business of pharmacy is unique in this regard. No other retailer anywhere operates blindly with regard to profitability.

MAC Pricing

MAC prices are the upper limits that a PBM or plan sponsor will pay for generic drugs and brand name drugs that have generic versions available. The pricing methodologies behind these lists are not transparent. They are considered proprietary, and according to the Academy of Managed Care, if MAC price information were publicly disclosed, it would have an anti‐competitive effect on health plans, employers and other payers.

MAC pricing and reimbursement below cost (RBC) is not new to independent pharmacy. MAC lists have been around for years, and when an RBC transaction occurs, there is an appeal process for asking the PBM or plan to consider changing the MAC price of the drug. MAC appeals often involve sending a copy of an invoice as clear evidence that the drug was indeed priced below the acquisition cost.

Unfortunately, the success rate of these appeals has plummeted over the last several years. As many as 94 percent of MAC appeals are denied, and there is no way to dispute the conclusion that the pricing is consistent with market conditions. Why not? Because the algorithm or methodology used to set the price is kept secret by the PBM or plan. Only in the business of pharmacy.

Good News – Bad News

The bad news is the list of challenges goes on to include such issues as Preferred and Restricted networks, Generic Effective Rate contracts, mail order, specialty drugs, and PBM consolidation and vertical integration. It is no surprise that many small independents, especially in rural communities, are closing their doors. A recent policy brief from the RUPRI Center for Rural Health Policy states that 1,231 independently owned rural pharmacies in the United States (16.1 percent) have closed over the last 16 years. This decline has continued through 2018, although at a slower rate. However, 630 rural communities that had at least one retail pharmacy (independent, chain, or franchise) in March 2003 had no retail pharmacy in March 2018.

The good news is these issues are getting noticed. There are many independent pharmacy advocates taking a stand and working to keep indies independent and viable. Also, state-by-state grassroots activity within the pharmacy community is beginning to bring awareness to legislatures across the country, and such efforts are getting some traction at the federal level as well. The recent removal of certain gag clauses in pharmacy contracts, as outlined in the 2018 Patient Right to Know Drug Prices and Know the Lowest Price Acts, is a good example of progress in the right direction. But it’s not enough. Further reform is greatly needed, or patients in small towns and rural communities across the country will continue losing access to quality care.

You may be asking, what can I do to protect my pharmacy’s independence and financial health while continuing to provide customer care excellence for my local community? Choosing the right Pharmacy Services Administrative Organization (PSAO) is one very important step. Your PSAO should be on the front lines, working diligently on your behalf and providing the support services you need to stay competitive, operate efficiently, and do what you do best – serve your patients.


About the Author

Robert Dickey, MBA, is the Chief Executive Officer of Pharmacy First, a Pharmacy Services Administrative Organization serving more than 2,300 independent pharmacies. With a strong business, technical and entrepreneurial background, Robert has a successful track record working with key decision-makers to meet pharmacy business objectives. Robert has more than 30 years of experience managing cross-functional teams in a variety of industries including pharmaceuticals, pharmacy services, manufacturing, transportation and finance.

Clinical Quality: 2019 Medicare Star Rating Update

The Centers for Medicare and Medicaid Services (CMS) recently announced STAR rating measures for 2019, with improvements in clinical quality as the focus of patient care. Success in 2019 is going to be highly dependent on pharmacies knowing the quality metrics that require continued focus to drive 5-star thresholds.  As your partner in excellence, the clinical team at Pharmacy First has identified key quality metrics for 2019 and is here to support pharmacies in their clinical success.

Continued Focus on Adherence

The healthcare community understands the value of patient adherence on clinical outcomes and overall healthcare spend. Adherence continues to be at the forefront of clinical quality metrics, with the majority of 5-star adherence cut offs increasing in 2019. In order to be a top performer, plans must achieve adherence scores ranging from 85-89% for diabetes, hypertension, and cholesterol medications.

Maintaining patient adherence requires a multifaceted approach that begins with visibility to pharmacy performance data. Engaging EQuIPP on a weekly basis allows pharmacies to proactively monitor any late to fill patients and quickly act upon any outliers. When discussing adherence with patients, Pharmacy First recommends utilizing motivational interviewing with patients to understand barriers to care, and mediation synchronization and adherence packaging solutions to maximize patient success.

Comprehensive Medication Review (CMR) Completion

CMR completion rates experienced the largest increase in quality metric cut-points, with Part-D 5-star performance climbing nearly 20 percentage points to 72%. As a result, it’s imperative for pharmacies to routinely monitor CMR opportunities and engage eligible patients. Performing CMRs allows pharmacists dedicated time to engage with patients and identify any drug related problems, while simultaneously bringing in additional revenue for completion.

Pharmacies can complete CMRs on a variety of MTM platforms, including OutcomesMTM, Optum MedMonitor, and Mirixa. It is essential for pharmacies to be active on all three platforms, as utilization differs by payer. If your pharmacy needs assistance in enrolling in one of the many MTM platforms, the Pharmacy First customer service team is ready to assist.


Cardiovascular Care

In order to reduce the risk of cardiovascular events, CMS has added two new metrics to the 2019 Star Rating criteria. In 2019, statin use in patients age 40-75 with a history diabetes will be a weighted measure for both Medicare Part D and Medicare Advantage plans. Plans must reach a performance score of 82-83% to be a five-star performer and a champion of cardiovascular care. Additionally, CMS is monitoring statin use in patients with a history of cardiovascular disease for Medicare Advantage patients. In order to reach 5-stars, plans must have at least 85% of patients on a statin.

Statin use in these populations is critical to prevent potentially life-threatening cardiovascular events. Pharmacies are encouraged to utilize platforms, such as EQuIPP, to identify patients with current gaps in care. Many health plans recognize the importance of statin use and may provide paid MTM opportunities to engage patients and providers.



As your partner in excellence, Pharmacy First has a team of licensed clinical pharmacists who provide complimentary quality review sessions to members. Our pharmacists’ real-world experience, coupled with in-house data analytics, allows Pharmacy First to provide expert guidance on improving clinical outcomes in a manner that doesn’t compromise operational efficiency.

Our clinical pharmacists, Todd Wormington and Katelyn Strauch, are passionate about independent pharmacy and dedicated to your pharmacy’s success. Connect with our clinical pharmacists to schedule a one-on-one time to review your pharmacy’s current performance and create a strategic plan to maximize clinical quality metrics. For more information, or to schedule a clinical quality review, call 800.460.1575 x301 or email programs@pharmacyfirst.com.

About the Author

Todd Wormington is the Director, Pharmacy Programs for Pharmacy First and has over 25 years of pharmacy industry experience. His work as a practicing pharmacist helped frame a passion for direct patient care and led to a career focused on the clinical and operational resources required to deliver enhanced pharmacy services in a community-based setting.