Performance-based pharmacy payment models: key components and critical implementation considerations for successful uptake and integration

BACKGROUND: In the United States, the shift towards value-based health care seeks to improve patient outcomes while reducing health care spending. Although the federal government has led the implementation of performance-based models for physicians and health care systems, commercial entities have largely been responsible for the development of similar models within pharmacy. For the purposes of this study, performance-based pharmacy payment models (PBPPMs) were defined as prescription drug payment models that determine reimbursement or fees for community pharmacies based in part on measured performance. These PBPPMs incentivize pharmacies to improve patient care by linking reimbursement to performance measures. However, the design and implementation of PBPPMs lack transparency and have not been described in the literature. OBJECTIVES: To (1) describe the structure of PBPPMs in the United States and (2) identify contextual and motivational influences that need to be considered for successful uptake and integration of these models. METHODS: A search of peer-reviewed and grey literature was undertaken. In addition, semi-structured stakeholder interviews were conducted with a convenience sample of 17 individuals who were community pharmacists, payers, quality measure developers and vendors, academics, and pharmacy advocacy organization leaders. Data were analyzed to understand the current structure of PBPPMs and opportunities for improvement, as well as implementation considerations that included facilitators, barriers, and key insights. RESULTS: This study identified 4 major components of US PBPPMs: attribution, performance and quality measures, incentive structures, and patient care services. A number of barriers (eg, lack of alignment) and recommendations to improve the current structure of PBPPMs (eg, the need for adequate incentives to facilitate change) were highlighted. Notable implementation considerations centered around (1) establishing common ground among stakeholders to avoid misalignment and encourage engagement; (2) the importance of a quality-driven, innovative, and flexible organizational culture with access to data infrastructure, adjusted workflows, and relevant trainings; (3) supporting the cultural transition to value-based health care; and (4) application of financial incentives at the pharmacy or pharmacist level. CONCLUSIONS: To better develop and implement PBPPMs, it is first critical to understand the key components that define these models and the needed changes to their structure. In addition, identifying the contextual and motivational factors that influence their successful integration can improve future uptake. This study illustrates the landscape of PBPPMs in the United States, as well as makes recommendations for improvement in their design. To improve future development and implementation of these models, the following recommendations are highlighted: (1) increase transparency and alignment of measures with the incentive structure; (2) embrace innovative business models; (3) carefully plan and use roadmaps that outline successful uptake and implementation; and (4) foster culture of quality at all levels of health care.