Shared savings contracts with managed care entities have become increasingly important components of facility financial management plans. While these models often don’t offer healthcare organizations the same revenue potential as fee-for-service arrangements, they are an essential part of the new healthcare world where all players accept more risk and accountability.
Risk-based agreements have become fairly standard for medical procedures and hospital care, but they are still developing for pharmacy. When hospital pharmacies buy and receive reimbursement for newly available drugs, for instance, there is still uncertainty about the benefits those drugs will provide, especially over the long term, says Tracy McDowd, PharmD, senior billing consultant at HCA.
“Typically, only clinical trial information is available at the time of product launch, so there are still questions about the efficacy and safety of the drug in the general population,” McDowd says. “Often, questions remain regarding the drug’s impact on long-term outcomes, and the overall budget impact for payers and providers may be hard to predict.”
In an uncertain environment, entering into risk-based agreements for pharmacy outcomes is a delicate process that continues to evolve.
Pharmacy Concerns
All risk-sharing agreements are not created equal—and no facility can reasonably be part of all of them. “Payers and providers only have the capacity to properly participate in a few outcomes-based deals at any given time due to the burden of data collection,” McDowd says.
For facilities, the most common potential risks include:
• Clarity around the outcome measures being evaluated
• Ability to standardize treatment protocols to ensure patients are treated consistently
• Determining and enrolling the appropriate patient population
• Having the data infrastructure to appropriately capture outcomes
For pharmacies specifically, it’s important to consider appropriateness of the medication, objective measured outcomes and timeframe of the agreement, says Bradley Bruce, PharmD, corporate pharmacy leadership resident at HealthTrust. Each of these items can vary from one agreement to the next with managed care entities.
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