Earlier this week, I published a guest post on the Pharmacy Quality Alliance blog discussing the gaps in the pharmacy delivery system and the opportunities that the value-based care models present.
Read more here: The Future of Pharmacy is Value-Based
In this follow up post, I’m going to introduce you to our philosophy and approach to running value-based programs. This is how we make innovation a reality and keep patients our top priority. My goal is to put a little structure around this complex ecosystem for payers, pharmacists, residents, students, and anyone else interested in this space. Our framework gives you a way to design, launch, and scale any value-based programs. You dream it, we build it.
Now the fun part.
DocStation’s Value-Based Framework
At DocStation, we help health plans and pharmacies connect to run value-based programs that improve outcomes and lower costs. We use the word “program” to describe all the intricacies of providing care and managing risk across a population. This includes:
- Patient Care — documentation, outreach, scheduling, referrals, care coordination, communications, workflow management
- Program Management — risk stratification, targeting, performance measurement, reporting, analytics, compliance
- Network Administration — contracting, credentialing, quality assurance, payment
We’ve built a two-sided software platform that functions as a turn-key population health powerhouse. On one side, payers use DocStation to design, manage, and monitor value-based programs in real-time. On the other side, DocStation functions as a world-class practice management solution pharmacists use to build and grow a clinical practice. DocStation has an incredible software design that provides a seamless experience for both payers and providers to manage patients as a team. How do we do that? It starts with program design.
Value-based programs can be used to manage a variety of different member populations: Medicare, Medicaid, Dual-Eligible, SNP, CHIP, Commercial, etc. Their main difference when managing one population from another are the quality measures and compliance. We start by determining the patient population to focus on.
Defining the population up front allows us to tailor a program specific to those members. From there we configure the program in DocStation, including the appropriate quality measures, automated reports, and other requirements needed to run a successful program for that population. We’ve also built some pretty awesome program management tools that enable our team to configure multiple programs across multiple plan types so payers can manage several unique value-based programs across their entire book of business.
Once one or more value-based programs are configured on DocStation, the next step is implementation. That starts with data integration.
We’ve built a data pipeline that enables us to ingest pretty much any type of data source, but the most common ones we see are medical claims, pharmacy claims, eligibility files, formulary details. We also connect to a variety of external sources including pharmacy dispensing systems and state immunization registries to produce a comprehensive view of the patient for both the payer and the pharmacist.
The better, more accurate data we have to start with, the more powerful we can get with risk stratification, targeting, and eventually, closing the gap. Before we can do that, we need pharmacists to provide the care. Outreach is done a variety of ways today, from internal staff at a health plan doing it in-house to hiring a vendor with a call center to handle engagement to delegating work to external pharmacist providers.
Our philosophy is that pharmacists embedded in communities with strong relationships with members and their caregivers are the most powerful, underutilized resource today. In order to leverage those pharmacists, we need a quick way to connect them with the health plan to participate in the program.
We help payers recruit, onboard, credential, train, and support a clinical pharmacy network. At the beginning, we had to do a lot of this work manually. We’ve now built tools and workflows that make this process smooth. If we already have a network in place, it only takes a few clicks to add another program to a pharmacy’s repertoire.
In order to close gaps and achieve the outcomes we’re looking for, a number of things still need to happen, including development of member attribution, member targeting for gap closure, documentation of gap closure, quality reporting and performance calculation, and pharmacy payments. We’re still seeing a lot of manual processes and spreadsheets out there, so we figured the best way forward is automating everything in DocStation. It took us 18 months to implement our first program. Our most recent one took 6 weeks and it’ll get even quicker. Our goal is to configure and launch a program in real-time and make those tools available to health plans so they can manage programs without us sitting in the middle. Pretty cool, right?
Once a program is designed and implemented, we need to track performance. That means we need to take all the different data streams we hooked up during implementation and calculate quality metrics. While most programs to date rely on claims data alone, we’re pulling in pharmacy dispensing data to get a more accurate picture on adherence, immunization data from state registries to get clarity on immunization compliance, and clinical data from point-of-care testing conducted at the pharmacy. This gives us a whole new way to calculate performance.
Performance is typically calculated in aggregate at the plan-level and individual pharmacies have no idea if they are meeting the mark or not (part of the reason why pharmacies hate DIR-fees so much). We expose both plan-level and pharmacy-level performance right from the DocStation dashboard and, in order to make the program truly value-based, we tie pharmacy payments to performance on these quality measures.
Value-based contracts and payment incentives can be structured in a variety of ways, from fee-for-service to shared savings. As long as you have the data to calculate performance quickly and accurately, you can set up any type of value-based incentive you want. That’s the beauty of software automation.
Through all of this, it’s important to keep in mind the true end goal. We want to improve outcomes and reduce total cost of care. Tracking measures and proving outcomes with any clinical program is complicated at best. There are multiple programs running at the same time with the same pool of patients. There are several different providers and facilities interacting with the same pool of patients. There are social determinants impacting one group of patients, but not all, and we’re not sure which ones. Like I said… complicated.
The important thing is that we track metrics like blood pressure at goal, hospitalizations, ED visits, readmissions, pharmacy spend, medical spend, and patient satisfaction. We track it, not just for one performance year, but for many. We’re talking about a multi-year investment in your members and your business. When it pays off, it pays off big.
Data is going to get more plentiful, more accurate, and more insightful over time. We’ll build hypotheses, make assumptions, draw conclusions, and show correlation. The more insights we gain along the way is going to make us smarter in the future. That’s when the really, really big payoff happens for everyone and that’s what our industry is going to look like for the next 10 years.
DocStation gets pharmacies paid for services. Pharmacies use DocStation to provide care, auto-bill medical claims, and participate in value-based programs with innovative health plans.
Get started today and discover how easy it is to get paid for the services you provide every day when you partner with DocStation.