Examining the case for direct contracting: A multistakeholder case study.

BACKGROUND: Employers and pharmacies are challenged by a complex system for prescription payment. Cost plus direct contracts for prescriptions and bundled services may yield benefits. OBJECTIVES: This study aimed to (1) explore direct contracting using multistakeholder interviews, (2) compare employer costs and employee copays for 6 months of prescription charges under their pharmacy benefit manager (PBM) with projected costs under a pharmacy direct contract, (3) project pharmacy revenue, costs, and net profit had these prescriptions been processed through the direct contract, and (4) assess employee satisfaction under the direct contract. METHODS: Semistructured stakeholder interviews were recorded transcribed and analyzed to identify different perspectives on direct contracting. Employer PBM invoices for 412 employee prescriptions over 6 months were analyzed to calculate employer and employee costs and reanalyzed for the invoice cost plus $12 professional fee direct contract. For the pharmacy financial analysis projection, invoice costs and a $9.82 cost of dispensing were subtracted from total revenue to yield an estimated profit had the parties been under the arrangement. A 34-item satisfaction survey was mailed using a 4-contact design with cash incentives to the 20 employees serviced by the direct contract that were analyzed descriptively. RESULTS: Eight stakeholder interviews described the benefits and potential challenges of such direct contracts. The financial analysis suggested the employer costs would be $5664 lower and employee copays would have been $1918 lower had all prescriptions been paid using the direct contract. The estimated profit for the pharmacy was projected at $899. Survey respondents were generally satisfied with the direct contract, but few used the bundled services. CONCLUSION: The direct contract may be financially beneficial for all parties. It also may offer more transparent pricing that may be desirable for the employer and pharmacy. Greater uptake of bundled services may increase the value to the employer.

Use of medication regimen complexity to target services in the community.

BACKGROUND: In the community, successful medication therapy depends on patients managing complex medication regimens. To assist, pharmacists can sort patients on the basis of their regimen complexity and then tailor care appropriately. OBJECTIVES: Objectives were to (1) develop a medication regimen complexity score and assess its reliability and validity, (2) design and implement a Less Complex program to tailor medication management services to the complexity of medication regimens, and (3) evaluate the impact that a Less Complex program had on identification and resolution of medication-related problems (MRPs). METHODS: Patients in the Less Complex program were stratified into complexity categories on the basis of Iowa Medication Complexity Scores (IMECSs) to receive pharmacy services tailored to their complexity category. Types and numbers of MRPs identified and associated pharmacist interventions were extracted. Frequencies and descriptive statistics were calculated. To assess the reliability and validity of the IMECS, a stratified random sample of 125 patients was drawn. For each of these patients, baseline and end of 9-month scores for IMECS were compared with Medication Regimen Complexity Index (MRCI) scores using paired t tests. RESULTS: A total of 661 patients had both baseline and post-IMECSs. The mean IMECS for the sample of 661 patients decreased from 28.6 at baseline to 27.3 during the postperiod. For the stratified sample (n = 113), the MRCI showed a nonsignificant change from baseline to the end of treatment period, whereas the IMECS showed a statistically significant decrease from baseline to the end of treatment period. A total of 10,535 MRPs and 10,482 interventions were documented during the 9-month treatment period for 1019 patients. CONCLUSION: Evidence supported initial reliability and validity of the IMECS. The Less Complex program identified and addressed many MRPs by matching patient complexity to service type. Future work is needed to evaluate a similar approach in other pharmacies.