Optimizing Medication Spend within Value-Based Care through the High-Value Pharmacy Enterprise

Document Type

Conference Proceeding

Publication Date

1-8-2025

Publication Title

Am J Health Syst Pharm

Abstract

Purpose: As healthcare reimbursement models evolve from traditional fee-for- service to value-based care (VBC), organizations must meet stringent cost and quality benchmarks to maintain competitiveness. One significant challenge in this transition is the fragmented management of pharmacy and medical benefits, especially concerning high-cost medications. This siloed approach often obscures the full scope of medication expenditures and their impact on patient outcomes and financial performance under VBC contracts. The objective of this project is to integrate and optimize the management of pharmacy and medical spending through a High-Value Pharmacy Enterprise (HVPE) model, aiming to improve reimbursement, enhance patient care, and mitigate financial risk. Methods: To optimize value-based care contracts and manage pharmacy and medical spend, a detailed analysis of key metrics will be conducted. This includes examining reimbursement differences between pharmacy and medical benefits, focusing on high-cost specialty medications. The project will evaluate bundled payment models for high-opportunity therapies and assess cost-saving opportunities by transitioning from intravenous infusions to self-injectable therapies where clinically appropriate. A case study involving ocrelizumab, an injectable medication for relapsing and primary progressive multiple sclerosis, will serve as the starting point. The recent approval of a subcutaneous version, which can be self-administered, presents a lower-cost alternative to intravenous infusion. The analysis will consider the financial impact of moving patients from clinic-administered infusions, which incur fees related to nursing time, chair occupancy, and administration, to self-administration through the pharmacy benefit. By shifting the site of care and reviewing authorizations more proactively, we anticipate significant cost reductions. Additionally, the project will involve collaboration across pharmacy and medical teams to implement a streamlined process for ongoing review of high-cost medications, ensuring that cost-effective alternatives are consistently explored. We will integrate clinical pharmacy services to oversee these transitions and ensure appropriate monitoring. The outcome of this case study will inform broader implementation across the health system, establishing a standardized approach for transitioning medications to reduce overall cost of care, enhance clinical outcomes, and improve financial sustainability of VBC contracts.

Volume

82

First Page

S1270

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