The independent community pharmacy is under siege from emerging mail-order drug services, pharmacy chains like CVS and Walgreens and declining reimbursement rates, but as Flaviu Simihaian likes to point out the segment is holding steady at around 35 percent of the country’s retail pharmacy space.
Simihaian is the CEO of Troy Medicare, a Charlotte, North Carolina-based Medicare Advantage startup looking to leverage these independent pharmacists to help deliver care and manage the chronic conditions of seniors.
Simihaian previously helped start a company called Amplicare, which provided workflow automation software for pharmacies. It was in this role that he started to see the potential of pharmacists as a key cog in care delivery.
Instead of just filling prescriptions, he witnessed pharmacists providing health assessments, helping overcome patients’ social barriers to care and helping patients understand how to keep healthy and stay adherent to their medications.
“There’s this idea that pharmacists are just pill dispensing machines, but there’s a reason they continue to stay around even with everyone healthcare is effectively trying to put them out of business,” Simihaian said. “They stay because they have developed a trusted relationship and provide a much higher level of care for their patients.”
Medicare Advantage is a rapidly growing segment within the insurance industry, driven by favorable federal policies which allow more flexibility in how plans operate. Because of Medicare Advantage’s capitated payment model, health plans are incentivized to figure out new ways to coordinate care and keep patients healthier and out of the hospital.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
According to research sponsored by AmeriSourceBergen, patients interact with their pharmacist 35 times a year versus only four visits with their provider. Troy is betting that these touch points can be more effectively used to manage chronic diseases, ensure medication adherence and deliver preventive health measures like flu shots.
Amina Abubakar, the owner of Rx Clinic Pharmacy in Charlotte, North Carolina and Troy’s clinical director, said in her normal practice she delivers medications to homebound patients, put together medication adherence packages and works with patient’s clinicians on their care.
She said that the problem is that these actions don’t receive any commensurate reimbursement from health plans.
“We still get paid only for the pills we dispense,” Abubakar said. “These things we do are so important to drive better outcomes, but no payer seems to actually value them.”
Troy Medicare’s model is based on paying pharmacists directly for those care management services at a rate of between $30 to $50 per-member-per-month.
Where Troy’s technology comes in is in developing a data infrastructure that will allow the cross sharing of pharmacy and medical claims data to help improve care coordination between a patient’s provider and their pharmacist.
“A lot of times we just don’t know if a patient was discharged from the hospital,” Abubakar said. “If we can improve that turnaround time and reach them earlier, then we have a high chance of preventing readmission.”
Doctors, in turn, can benefit from the insight that pharmacists provide to help build better care plans that patients will be more likely to stick to.
In order to ensure a standardized level of clinical services across its pharmacy partners, Troy is working with Community Pharmacy Enhanced Services Network (CPESN). The organization is a network of clinically integrated pharmacies which provide enhanced clinical services meant to reinforce and support patient care plans.
Troy is using the National Average Drug Acquisition Cost (NADAC) figures to help price its prescription drugs. The NADAC reference data is a weekly estimate published by Medicaid of the average drug invoice paid by independent and retail chain pharmacies collected through surveys.
In Troy’s model the NADAC numbers will be used to determine drug reimbursement and pricing levels for pharmacists by adding a dispensing fee of $10 for generic medications and $4 for branded drugs.
The tabulation flips the way pharmacy contracts normally work, which are based off of negotiated discounts from drug maker listing or wholesale prices.
“The way it is today, you don’t know what the prescription is going to cost if you’re senior, or if you’re a pharmacist you have no idea what you’re going to get paid,” Simihaian said.
Troy’s MA plan is being offered in 2019’s Open Enrollment period with a modest 1,500 member first-year enrollment goal. The company’s plan is launching in Iredell, Cabarrus, Rowan, Granville, and Robeson Counties in North Carolina, which are relatively rural areas in which independent pharmacy owners play a larger role in the community and have existing provider relationships.
Still, it will be an uphill journey. Traditional insurers like UnitedHealthcare and Humana dominate the Medicare Advantage space and upstarts like Devoted Health and Clover Health have raised hundreds of millions of dollars as they try to edge their way into the market.
Troy’s $5 million Series A round pales in comparison to those numbers and the insurer is still in the midst of building out its provider network in the communities it wants to operate in.
Where Simihaian sees his company’s advantage is through leveraging the existing trusted relationships between patients and their pharmacists as a distribution and promotional pathway for Troy’s plan.
While Troy is initially working only with independent and community-based pharmacies the hope is to eventually and drive better health by engaging more even larger retail pharmacies in more care delivery.
“Repeating the same old same old hasn’t given us better outcomes. We need to take pharmacists outside of their box and leverage the touches they already have with patients,” Abubakar said. “It’s a perfect storm, we’ve moved from fee-for-service, to value based care and we need everybody on the bench and all hands on deck.”
Picture: Hiraman, Getty Images
