Five Value-Based Care Predictions for Pharmacy in 2025

Todd Sega, Managing Director of Pharmacy at PQS by Innovaccer, predicts five key changes will drive pharmacy’s value-based care evolution in 2025 in this PQS Quality Corner Show episode.

Nick Dorich, PharmD, PQS Senior Manager of Pharmacy Accounts, acts as host on this episode and interviews Todd on key changes to non-dispensing revenue opportunities, pharmacy-payer partnerships, medicare market changes and more.

Transcript

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00:00:01:04 - 00:00:16:05

Todd Sega

By helping to move the needle on these non MTM bigger view programs is creating a bonus pool in a dollar amount that will be placed in front of pharmacies in 2025 that most pharmacies just haven't seen yet.

00:00:16:06 - 00:00:39:08

Todd Sega

So obviously it may not be pharmacy A, pharmacy B, but broadly across the marketplace we're seeing some value-based care agreements and bonus pools hit some true bonus-only dollar amounts that we've just never seen before. And that's in stark contrast to potentially what may be out there for CMRs or reimbursement on other MTM related items.

00:00:41:17 - 00:00:45:15

Voice Over

Welcome to the Pharmacy Quality Solutions Quality Corner Show,

00:00:46:06 - 00:00:51:10

Voice Over

Buckle up and put your thinking cap on. The Quality Corner Show starts now.

00:00:51:21 - 00:01:02:13

Nick Dorich

Hello Quality Corner Show listeners, welcome to the PQS podcast where we focus on medication use, quality improvement and how we can utilize pharmacists to improve patient health outcomes. I'm your host, Nick Dorich.

00:01:02:15 - 00:01:15:23

Nick Dorich

On today's show, we have a special and returning guest. It's my colleague here at PQS by Innovaccer Todd Sega. Todd is the managing director of pharmacy here at PQS by Innovaccer. Todd., welcome back to the show. How are you doing today?

00:01:16:05 - 00:01:20:06

Todd Sega

Doing great. Excited to be back to cap off 2024.

00:01:20:09 - 00:01:41:08

Nick Dorich

Yeah. This year has gone by incredibly fast and it's been a really exciting year for us at PQS by Innovaccer, a really exciting year for pharmacy's around engagement and moving towards more value-based care opportunities, which folks that's what we're going to be talking about today. For this episode, I brought Todd on, and we're going to be covering this really exciting topic about how we continue to move pharmacy forward into value-based care.

00:01:41:10 - 00:01:55:02

Nick Dorich

But, Todd, before we get to that, let's get a quick introduction or reintroduction, because some folks, if they haven't listened or check out the show before, they might not know who you are. So you do you mind giving us a quick introduction? You know who you are and what you do here at PQS by Innovaccer.

00:01:55:10 - 00:02:35:05

Todd Sega

Yeah, sure. Happy to do so. So excited to be back. Thanks for listening in. So I am a pharmacist by background and spent my earlier part of a career working in community pharmacy, and that's where I developed most of my passions in pharmacy and helping to create change. Also likely because of a lot of involvement in state associations, whether that was with the National Association of Chain Drug Stores or I know our paths first crossed, Nick, as well as the Ohio Pharmacists Association, where I just had some absolute great mentors who were in the association world, but also some independent owners that I was able to connect with and learn from and love

00:02:35:06 - 00:02:48:06

Todd Sega

being a part of the movers and shakers, and developed a passion to try and connect payers to pharmacies to create more change and opportunities that would come to community pharmacy. So that's when I had a career path

00:02:48:06 - 00:03:12:21

Todd Sega

that took me back into association management, and from there saw this awesome opportunity to bring pharmacy into value-based care. And there is a company just launching at the time, which was PQS and made the leap to come over and have really enjoyed the last ten years growing and learning at PQS and helping to bring change to the marketplace.

00:03:12:23 - 00:03:24:11

Todd Sega

And so today I'm the managing director, as you mentioned. So I oversee our pharmacy business unit at Innovaccer, working with some of our other business units and other verticals. Now that we're a part of a larger company.

00:03:24:20 - 00:03:44:13

Nick Dorich

Fantastic, Todd. And yeah, great to have you here for this episode. And let's get into our conversation. Our discussion for today. I mentioned it earlier right off the cuff from as we started this, the show, we're going to be talking about value-based care and how we can catapult pharmacy, the pharmacy community pharmacy practice, into that world.

00:03:44:13 - 00:04:02:06

Nick Dorich

Now, there are parts of pharmacy practice that Todd, you and I know. And for our listening audience, there are parts and there have been aspects of pharmacy, that are involved with value-based care. But, you know, really most of the healthcare world, at least here in the United States, is looking to move towards, towards a more expansive value-based care.

00:04:02:06 - 00:04:22:06

Nick Dorich

So as we want to get pharmacist and pharmacy paid like other providers, guess what that means, folks? It means we're going to have to adapt, means we're gonna have to work through value-based care and just, you know, broadly for us or taking a quick timeout, let's define value-based care. value-based care. It's a health care model focusing on quality of care, patient experience and provider performance.

00:04:22:06 - 00:04:54:23

Nick Dorich

This is all done with the goal to improve health outcomes while also reducing cost. So the idea here is a better patient experience or better patient outcome. It's reducing really the number of services that a patient needs to get or to receive, but at the same time improving the health outcomes. So with that there's a lot of changes that need to occur, a lot of synergies that need to be exercised, and a lot of work that we still need to do to get to that, to that place where they pharmacy as a location, but the pharmacist and the pharmacy team members are a part of that active value-based care team.

00:04:55:04 - 00:05:16:03

Nick Dorich

So, Todd, we've gone through a bit of an exercise and you've done a lot of the legwork on this one, admittedly, to get through and identify what are going to be some of the most impactful changes that need to occur to facilitate pharmacy involvement in value-based care. And I'll preface this by saying some of these are items that internally in the community pharmacy or in the pharmacy community internally

00:05:16:03 - 00:05:33:02

Nick Dorich

for us, some of these need to happen. Some of these are have to be changes that happen inside the pharmacy. Some of them are going to be changes that health plans and payers need to engage with to help facilitate this. And then there's going to be some kind of third bucket that will be other aspects, whether it's vendors or regulatory changes that help facilitate this.

00:05:33:02 - 00:05:51:09

Nick Dorich

So, Todd, you've identified some areas that need to be that where there's going to be changes to help facilitate this, this change. Let's go through and can you outline what those five items are to get us started. Everybody can kind of take their notes to get an idea of what's coming ahead. And then we'll deep dive a little bit into each of those topics.

00:05:51:09 - 00:05:55:04

Nick Dorich

So I'll hand it off to you here. What have you identified?

00:05:56:06 - 00:06:29:03

Todd Sega

Yeah. Thanks, Nick. So for those five areas, obviously there could be more, but at least the top five that we're looking at in our crystal ball, we believe that 2025 is going to have some of the highest increases in non dispensing revenue opportunities that the marketplace is seeing. We also see a lot more scrutiny and evaluation on the results of programs that payers may take with pharmacies in that value-based care arena.

00:06:29:05 - 00:06:58:09

Todd Sega

And then we also see some marketplace changes to your internal and external point in Medicare Part D, with some changes and consolidation exits in the marketplace that are going to have an impact. And then we also see this as one individual can't win it. So those who are able to think about delegation of tasks as a key win for value-based care, and then finally, workflow solutions are going to win in 2025 or beyond.

00:06:58:09 - 00:07:19:04

Todd Sega

If you can't get into the workflow in the in the pharmacy, can't operationalize it in their workflow for a value-based care program, it's really increasing the gradient of that slope for the pharmacy to be successful in those programs. So those are kind of the big five areas, and would love to to dive into some of those a little bit more detail with you.

00:07:19:06 - 00:07:40:03

Nick Dorich

Absolutely. So we're going to start there. And this is you know, these are, these are five, five items, as you said, out there, there are more considerations. But these are the five aspects. And it's not necessarily, you know, number 1 to 5 in terms of the most important, important. But these are all five things that need to be occurring somewhat simultaneously or are going to be occurring simultaneously in 2025.

00:07:40:05 - 00:08:03:21

Nick Dorich

So Todd, with that, the first item that you've identified, increased non dispensing revenue opportunities for pharmacies. And I'll cut right to the chase on this. This is something that the pharmacy community has been asking for, for years if not decades. Right. And I think a lot of the conversation on this topic has existed around, you know, the chicken and the egg scenario where if these opportunities are available, pharmacies will start to engage with them.

00:08:03:23 - 00:08:25:15

Nick Dorich

I think what we're pointing to here is that, hey, these opportunities are existing for 2025. It's no more chicken and the egg. It's happening in pharmacies. This is really a time to engage and to maximize the opportunities that are going to be there. So, Todd, I'll let you kind of expand upon this and get into some of the nitty gritty details that are going into the background as to why this is occurring now in 2025.

00:08:25:19 - 00:09:13:07

Todd Sega

Yeah, sure. So on the payer side, it's unsurprising, typical for most businesses, you're trying to make the most efficient use of resources. So for those who have investments that they want to make, they want to know what those returns are. And we have seen a pretty big decrease in the star ratings for payers for the 2025 star ratings, obviously reflective of data from 2023, but still, the decrease that we've seen has had payers pick their head up a little bit and say we need to either do more with the channels that we have, or we need to open up other channels for improvement initiatives.

00:09:13:09 - 00:09:40:22

Todd Sega

And this goes way back to a study that CMS did probably 6 or 7 years ago. But they looked at how many quality improvement initiatives a health plan sponsor typically had, and the sweet spot was 11. So it can't just be a provider led strategy. It can't just be an internal outbound call center approach from the payer. It can't just be mailers.

00:09:40:24 - 00:10:06:02

Todd Sega

It can just be care coordinators at the plan. But it really needs to have multiple layers to it. And that's where pharmacy and the touch points that pharmacies have represent an absolute channel to impact the member. So when you think about this, one side of the payers was saying, well, our scores have dropped. We have this investment part where maybe they want to be completely a five at the end of the five.

00:10:06:02 - 00:10:29:07

Todd Sega

That's great. But some may say you've overspent a bit if you didn't need to get to a total five star level, but you also don't want to be below four star, since four star is the cutoff for payers to get the quality bonus payment. So for those that are down. So for four star and above the percent of membership, that's in a four star above contract, just down 12% from the prior year.

00:10:29:09 - 00:10:52:13

Todd Sega

So you may say it's only 12%, but 12% across, you know, tens of millions of lives is a pretty good number. And that bonus payment multiplied per member per month. It has a pretty big impact. So that's a driver. And we also see even the five star contracts. There are very few standalone five star contracts at this point.

00:10:52:13 - 00:11:17:05

Todd Sega

So now that's down to almost seven. So since that's a single digit, you have less of those players in that space. But yet you have a demand for more of these quality improvement initiatives to take place because they're needing to increase their scores from where they were before. So that's sort of one point related to it. And then the other is another regulatory change with the star ratings.

00:11:17:05 - 00:11:44:03

Todd Sega

Obviously, we know the CMS completion rate has shifted from a star to a display measure for a couple of years. While it goes some retooling and some updated specifications due to updated eligibility criteria, which I know will expand that pool. But I think that the drop in some of the ratings are helping to drive a broader thinking. Along with the absence of CMR.

00:11:44:03 - 00:11:50:20

Todd Sega

MTM just isn't necessarily a top of mind service or action item.

00:11:50:20 - 00:12:33:15

Todd Sega

So it's really more about what are the services that pharmacies can perform that can impact quality, add value, and enrich the member experience. So I think those two things combined are spooling up a bit more demand for payers to say, what can our programs look like? They're not going to be necessarily MTM programs, but how can we be unique, more creative about the types of programs in offering different programs that we've never seen before, even related to formulary, so impacting the drug spend component to this, how do pharmacies become a more active participant in ensuring formulary compliance, medication affordability and access, and a

00:12:33:15 - 00:12:48:11

Todd Sega

partner not just working against the payers saying, hey, your health plan has a PA won't require that, but how do we actually bring those two together? And we're seeing payers start to think like that. And as a result, the value that can be unlocked

00:12:48:11 - 00:13:03:12

Todd Sega

by helping to move the needle on these non MTM bigger view programs is creating a bonus pool in a dollar amount that will be placed in front of pharmacies in 2025 that most pharmacies just haven't seen yet.

00:13:03:13 - 00:13:26:15

Todd Sega

So obviously it may not be pharmacy A, pharmacy B, but broadly across the marketplace we're seeing some value-based care agreements and bonus pools hit some true bonus-only dollar amounts that we've just never seen before. And that's in stark contrast to potentially what may be out there for CMRs or reimbursement on other MTM related items.

00:13:26:15 - 00:13:28:04

Todd Sega

So, you know, we're excited for that.

00:13:28:04 - 00:13:39:24

Todd Sega

And we think that's going to be one of the biggest drivers because we know pharmacists are looking in the corner for how do I diversify my business and where am I going to get some non-dispensing revenue. So that's kind of driver number one for 2025.

00:13:40:06 - 00:14:02:22

Nick Dorich

Yeah. And Todd that I'm going to kind of just segue us right to driver number two for 2025. And it's going to be about that payor pharmacy relationship and that sort of engagement that that exists. It is the sort of item where each health plan has or actually don't even take it a step back. Right? Each patient in each state, each region has their own different and specific needs.

00:14:03:03 - 00:14:21:07

Nick Dorich

The health plan, you know, the health plans that are out there based upon the members or patients that they are serving, they're going to have different performance trends, and that's going to influence why and what services they they want to incentivize. And working with both the providers and, in those pharmacies and network for them because, hey, everybody's going to be a little bit different.

00:14:21:13 - 00:14:38:12

Nick Dorich

You know, that means for pharmacy that to engage with these programs, you have to be a little flexible. You have to be able to be a little bit reactive because you know, how one payer may be supporting a program or or incentivizing services that may be different from the next payer, the next health plan that you've got down the street.

00:14:38:12 - 00:14:50:18

Nick Dorich

So, Todd, the second item I think you added identified really as the pharmacy-payer, you know, partnership and really delivering on these services. So, you know, what do you mean by that? And let's expand upon that topic.

00:14:51:01 - 00:15:20:09

Todd Sega

Sure. The segue I used to describe this with the expression to whom much is given, much is expected. So with point one more is being given to these dollar pools for pharmacies. So what's expected? Well, there will be some documentation. Is it going to be dollar for dollar for your minute, for the time you spent documenting? Maybe. Maybe not, but that's sort of the value-based care arena where you're moving from fee for service, watching the clock for every single minute.

00:15:20:11 - 00:15:46:21

Todd Sega

But hey, if I do X and my payment is Y, do I think that can be worth it? Across my population and those that's the shift in mindset from the pharmacy to think about that fee for service to participating in a performance based or value-based care program. So we definitely see a lot more scrutiny by plans to say, I really want to know what is it that that pharmacy is doing?

00:15:46:21 - 00:16:09:12

Todd Sega

It doesn't need to be some proprietary, confidential secret sauce that the pharmacy may have. But just what do you do and can I know for my member, what type of outreach did you do? Were you successful? Were you not successful? We want to know when you weren't successful as well. So having a little bit more expectation on the documentation requirements is definitely becoming a minimum threshold.

00:16:09:14 - 00:16:37:12

Todd Sega

And payers are very interested to say, well, who is willing to do that documentation and who's engaged? Because our prior strategy of just broadly throwing out across the entire network. Here's a program. Let's see who does what with. It is changing. So this increased scrutiny that I mentioned is shifting now to, “Hey, we may see more of a reemergence in high performing networks or high engaged networks. ”

00:16:37:14 - 00:17:01:00

Todd Sega

We definitely see a little bit of a shift in the term of CMS in term of preferred cost sharing pharmacies. That's not what we're talking about here. We're talking about who should be in the network for an enhanced service. Who's truly going to say, I understand the program, and I either don't have the resources or capability to do it.

00:17:01:00 - 00:17:32:01

Todd Sega

So I'm going to sit out. Don't say yes. If you're not going to have the ability to engage in the program. But for those who say, I am going to step up, we would love to see it, and the plans are wanting to see someone step up to do it, and they're very willing to say, even if that shrinks the network down to a smaller percentage, we'd like to engage with the pharmacies who are really wanting to engage in, interact with our programs, help us change some of our programs, and there will be dollars that will be there on the other side of it, as we're seeing with these increased amounts.

00:17:32:01 - 00:17:45:16

Todd Sega

So that's sort of what I meant by that. And we're definitely seeing a lot more interest there from payers to have evidence of the engagement, to know who's truly engaging or not in separating those, from each other.

00:17:45:22 - 00:18:03:17

Nick Dorich

I think of it, Todd, this is, just a very, very simple and straightforward, thought process that go to it in a lot of ways to me, it's kind of like Master Yoda from Star Wars. “Do or do not. There is no try.” It's really that part, right? As it goes to these sorts of programs. Can you produce the results and outcomes?

00:18:03:19 - 00:18:21:15

Nick Dorich

Because the payers do have specific, goals to achieve, and it's a part they were. If you're not able to help achieve those quality goals, then you actually may be hurting those quality goals here. So that part of it's going to be really important, to if you're going to engage, make sure that you can engage and commit around these services.

00:18:21:16 - 00:18:42:11

Nick Dorich

I think pharmacies can and are showing that they can do it. But just like I mentioned from the start, health plans are going to have different patient populations and different ways that they operate. Pharmacies are in different stages of readiness, in education and training and outreach. So there's a part there where there's going to be some, maturation, I think, for some pharmacy groups, some more than others to be able to address that.

00:18:42:13 - 00:19:05:23

Nick Dorich

Todd, beyond this, and you've already addressed some of these items around market changes. You talked about some of the changes around MTM, CMR, but 2025 for Medicare is going to be really kind of a seismic shift, more so than what we've seen or what the Medicare market has seen in a number of years. As we've talked about this with some of our pharmacy partners in Medicare open enrollment, there's not really seen as much of a change.

00:19:05:23 - 00:19:35:14

Nick Dorich

But what we know in speaking with our health plan partners is that this is one of the most drastic changes they've had year over year. Really, in the 20 plus years since Medicare Part D, has come around and come around to fruition. So can you explain, you know, what this what some of this is going to, to lead to and how this is impacting members or the patients when it comes to, you know, their interaction with the health plan that they are utilizing and how this could have an impact as well on the pharmacy where they are dispensing or where they're receiving, excuse me, their medications.

00:19:36:04 - 00:20:00:16

Todd Sega

Yeah. This is one where it's not necessarily to your point, the internal action needed by the pharmacy. It's an indirect effect that will impact pharmacy. And it is more of an exogenous shock or impact to the Med D space. And we could honestly spend more than an entire podcast going over all of the regulatory changes occurring for that marketplace.

00:20:00:18 - 00:20:33:16

Todd Sega

We're just going to I'm just going to highlight one for right here. But a lot of the implications of the Inflation Reduction Act coming into play for 2025 is definitely causing the players in the market to behave in what most would say a rational way, because reimbursement challenges are there. They have a little less flexibility in levers that they had because of some of the constraints, and then the cost setting by CMS on top drugs.

00:20:33:18 - 00:21:02:10

Todd Sega

But essentially we've had a lot of players leave the market more so than we've seen in prior years. And so these health plans that are terminating their Medicare or have terminated their Medicare contract for 2025, that's going to displace about 1.4 to 1.5 million Medicare Advantage lives. And when you take that across the entire U.S. population, yeah, you can see how that just gets absorbed in and actually falls out.

00:21:02:12 - 00:21:28:08

Todd Sega

But where these plans are going out of market isn't necessarily going to be evenly distributed across the board. So it may have more of an impact in these pockets of the country where there wasn't as much competition or let's say a pharmacy had more market share of this Medicare Advantage player, it's now left the market that's going to change the business dynamic, especially if it's under a different PBM contract, if it's a pharmacy that's accepting that.

00:21:28:10 - 00:22:00:16

Todd Sega

So those are the things that will cause a little bit more uncertainty on the reimbursement for the drugs themselves, because we already know we had this big shock coming from 2023 to 2024 with DIR change. And now needing to know that lowest cost possible, it really accelerated the bottom floor of that reimbursement, coupled with the carryover from 2023’s retrospective DIR payments.

00:22:00:16 - 00:22:23:22

Todd Sega

So that created this Q1 Q2 cash flow crunch in ‘24. But now you have at least more stability, stability with a lower reimbursement number, which isn't great. But now you just added a little bit more instability, potentially in certain markets, because you're going to have these changes, you're going to have different formulary switches. As I've now gone over to a completely different plan.

00:22:23:24 - 00:22:52:09

Todd Sega

And you may have member experiences that are going to change with the members as well, since they're interacting with a totally different plan than what they had before. So all of these things may result in a little bit more troubleshooting on 1.1 in January for pharmacies to help people process this new insurance or recognize that they need to educate the member a little bit more about you didn't just switch from plan A to B, but plan B also has a slightly different benefit profile.

00:22:52:12 - 00:23:15:04

Todd Sega

It may not have the same amount of supplemental, insurance benefits as well. So a lot of those changes are typically rear their head at the pharmacy. I know when I was working there, you end up having to explain how insurance works and what the donut hole was, and that's shrinking. So that will help in some respects. But the pharmacies tend to be front line when insurance doesn't work.

00:23:15:04 - 00:23:21:03

Todd Sega

And all of these changes could likely create some secondary impact in the marketplace.

00:23:21:03 - 00:23:22:13

Nick Dorich

So

00:23:22:13 - 00:23:43:03

Nick Dorich

yeah, it's sort of and we've covered this part right. There's a lot of aspects of it which may not be specifically touching the pharmacy staff or how they're working, but it does impact the patients. And ultimately, the pharmacy we know is the most common place where a a patient is seeing a health care provider or having conversations about their medical care or even just their benefits that relate to it.

00:23:43:03 - 00:24:08:04

Nick Dorich

So this is an item where I would expect that there's going to be a lot of questions here for pharmacy, pharmacy staff personnel in 2025. And but Todd, we're going to transition to the fourth item that you, highlighted. And this is something that, you know, we're going from an item that not really a whole lot, that's specific to the pharmacy to an item that is going to be, I would say, almost completely controlled by the pharmacy staff and by the pharmacy personnel.

00:24:08:08 - 00:24:35:04

Nick Dorich

And for that item, I am talking about the, delegation of tasks and really just kind of the pharmacy, pharmacy working experience. So this is an item where we have seen in recent years and a long running, progression where pharmacy staff, pharmacy technicians are able to do more services. We're also seeing state regulation changes where pharmacists are able to provide more services so pharmacists can do more, pharmacy technicians can do more.

00:24:35:08 - 00:24:50:08

Nick Dorich

But being able to do more if it's not done efficiently isn't necessarily helpful for us behind the counter or for the patient. So, you know, what were your thoughts on this topic? And you know what pharmacy needs to look at, What pharmacy needs to do to evolve for 2025?

00:24:51:03 - 00:25:17:04

Todd Sega

Yeah, it certainly takes a team to win. And we've heard that anecdotally from pharmacies where we check in and we see that they're just engaging and highly successful and some of our clinical and enhanced service programs. And when you profile that pharmacy, you find that it isn't just Jane Smith or John Doe, the pharmacist who says, hey, I print this out, I have a chase list, I'm on it.

00:25:17:04 - 00:25:48:04

Todd Sega

We're doing bag tags and we call our patients were highly engaged in it, but it's really where someone has said, oh yes, I check to see how we're doing, but I delegate that to our Stars or quality champion in the pharmacy. Having a champion that is secondary to whomever the main EQUIPP user was, or if it's not the pharmacist in charge or the pharmacy manager, but the EQUIPP user is the quality champion, and it happens to be the lead pharmacy technician.

00:25:48:06 - 00:26:12:16

Todd Sega

That's a great example of helping to delegate, and we see groups that have printed out different scores. Their goals of where they want to be in terms of helping to shift the needle from non dispensing opportunities to non dispensing revenue. And these folks will then print out where they are and where they want to be, and then they will post that somewhere in the pharmacy.

00:26:12:18 - 00:26:40:13

Todd Sega

And I think that's well relatively well understood that when you measure something people kind of flock to that. So measure what matters. And if this is a goal for the pharmacy, then we're helping to showcase what are the dollar opportunities that are available that I talked about in the first step, but let more than one person help win for the team and make sure that the entire team is aware of what that goal is and chasing towards it.

00:26:40:13 - 00:27:13:07

Todd Sega

So those are just some common best practices. And then we find out, you know, in our new world, as we get the chance to now interact a bit more with ACOs and risk bearing entities on the provider side, it's far more distributed. And obviously there's a lot more resources. Typically at the ACO where there are large care coordination teams working with the providers, but they make goals very available to a lot of the decision makers in the provider groups, and they're constantly updating and refreshing those so that everybody knows where people stand.

00:27:13:09 - 00:27:39:21

Todd Sega

But additionally, what role and what are the expectations of different staff members to help the entire organization hit that goal. So I would say in addition to delegation of tasks, it's just making those goals highly visible and informing the entire team so that everybody's bought in because you're going to win as a team. So that's sort of what I was meaning by those who delegate tasks and make it a shared win for the team.

00:27:40:04 - 00:28:00:02

Nick Dorich

Yeah, I think it's, I'll expand on that. Todd I think it's informing and empowering the staff. Right. Whether it's the pharmacy technicians, the pharmacist, to work through these activities, it's important I think most of us that have worked in health care or that do work in health care are doing because we have an interest in helping people, helping patients achieve their health goals.

00:28:00:04 - 00:28:23:14

Nick Dorich

And a lot of these different value-based, considerations are along those same pathways. So this is really a part here where it's to some extent, hey, how do you help your staff control your own destiny in moving that, that forward. But, Todd, we we've we've covered this is something that the pharmacy team, the pharmacy personnel can do internally, but there's going to need to be a little help and assistance that goes along with that.

00:28:23:14 - 00:28:44:23

Nick Dorich

And I think this goes into our the last item that you identified, which is going to be workflow solutions and capabilities. So obviously, you know, folks like ourselves at Innovaccer. And for the pharmacy teams themselves, you know, if it's an independent, they're using a dispensing system or a management system for a pharmacy chain. You know, they've got their support from their corporate office, from their clinical offices, etc..

00:28:45:04 - 00:28:57:02

Nick Dorich

So there's going to be help where it's not just the pharmacy staff in the physical pharmacy location. There's oh, there's that need to be involved. So what are you meaning? What are you indicating by this last item that you've identified?

00:28:57:10 - 00:29:43:22

Todd Sega

Yeah. This one, I'm probably the most excited for you. Even though it's hard not to get excited about the number of non dispensing revenue opportunities that are going to be available to pharmacy in 2025, but this is really built upon not just belief, but actual data from what Innovaccer has found. Having worked with providers over the last several years with a very similar product because they've realized on the ACO side, if the ACOs can't get into their provider workflows, the ACOs are unsuccessful to get their physicians to do what they need to do to act at the right time, take the right actions from all of this data and predictive analytics to help bend

00:29:43:22 - 00:30:28:07

Todd Sega

that cost curve for the ACO, unless they're in workflow. And so many of the groups with the the docs as well will try to have the slickest portal, the best EMR type integration. But it really needed to be a click -less integration within their workflow to change behavior to see the results. And I believe there was one health system that just reported a couple of weeks ago that when they looked at 2024 year to date, they had already calculated a savings of almost $9 million because they were able to get the physicians to act at the right time in.

00:30:28:07 - 00:30:48:21

Todd Sega

A physician said, thank you. I wasn't buried in my EMR to find what it was that I needed to do and win, because there was a solution that was a really powerful overlay on top of their EMR, which really act as more of a copilot to help guide them to super power, the EMR guided by the ACO.

00:30:48:21 - 00:30:56:20

Todd Sega

So when we look at this and think about the marketplace for pharmacy, we recognize that workflow solutions are going to win.

00:30:56:20 - 00:31:22:00

Todd Sega

If you can't help pharmacies operationalize what they need to do and when in that workflow, it's just a very, very steep gradient for pharmacies to have to push that boulder up the hill to try and convert nonprescription opportunities to actual revenue to complete those, so that more than just one person going to the team event can actually win for the pharmacy.

00:31:22:00 - 00:31:36:10

Todd Sega

So with that, I'm excited to share that we will have a new product that will hit the marketplace in 2025, and we will have a lot more information to come. I'd love to get back on the podcast, if I can, to talk about that product,

00:31:36:10 - 00:32:05:13

Todd Sega

but we have some folks that are beta testing this particular new product for us, right now actually, and this new product will help us do just that, get into that pharmacy workflow, prevent very high value opportunities to the right people at the right time, so that they can be more effective at switching over what exists out there to work on, to actually being worked on, and then getting additional

00:32:05:13 - 00:32:28:09

Todd Sega

revenue that doesn't even need the medical billing component. Since we are in Medicare for a lot of the programs where we're unlocking value and we still don't have that provider status, but yet there's still a lot of dollars on the line that can help really make up for potentially lost margins on the prescription drug reimbursement side. So that's where I'd say workflow solutions are going to need to be there.

00:32:28:14 - 00:32:38:18

Todd Sega

We're really excited to be able to have a product that we believe has really strong product market fit, and we've had some great reactions from our early customers in testing it.

00:32:40:03 - 00:33:07:15

Nick Dorich

Fantastic update there, Todd. I think it's this is an item where we preface this by saying there's going to be changes that are going to be coming. Some are going to be important for pharmacy, but also for some of the groups like ourselves, in reacting and really being responsive to what the customers, the pharmacy users, to be able to maximize these, these opportunities and really should be doing it from a standpoint to benefit the patients, the patient care activities that they're really driving forward in 2025.

00:33:07:21 - 00:33:41:09

Nick Dorich

So, Todd, I'm going to summarize things real quick for us and what we addressed today, looking at impactful changes for 2025 that facilitate or expand opportunities for value-based care with pharmacy. So we talked about increasing non dispensing revenue opportunities. We talked about pharmacy and payer partnerships about being able to deliver on these enhanced services. We talked about operational changes for Medicare and the multifaceted approach that is going to be occurring for those items.

00:33:41:11 - 00:34:05:06

Nick Dorich

These are going to be items that are going to be kind of payer directed or regulatory-directed, government-directed that impact, value-based care opportunities for pharmacy. And then when we get into the items that are more pharmacy controlled, that's about delegation of task and maximizing all the members of the pharmacy team. And then finally, workflow solutions and increasing capacity and capabilities to drive this engagement.

00:34:05:12 - 00:34:29:05

Nick Dorich

So there's, Todd, that's a lot of work for 2025. And I don't think that's all necessarily occurring just in 2025. But it's important to keep our eye on the ball and continue to make changes in our industry. That being the pharmacy industry, specifically the community pharmacy industry, to ensure that we're keeping our, that we're keeping one foot in front of the other, and that we're continuing to show progress on these items.

00:34:29:07 - 00:34:50:16

Nick Dorich

Now, Todd, as we wrap this up here, what do you think for 2025? Is this going to be a good year for community pharmacy? That's a lot of things that and change can be painful. But I think I get the sense from you as well that these are all changes that are realistic, that these are changes and, well, some not just realistic, they are going to be happening, but these are going to be positive changes for pharmacy at the same time.

00:34:50:16 - 00:34:54:06

Nick Dorich

So, you know, what are your closing thoughts about what this means for pharmacy.

00:34:54:19 - 00:35:24:03

Todd Sega

You know I consider myself as more of a realist. So not necessarily a pessimist or an optimist, but I, I would say as I look at 2025, I have to push myself and say, even being a realist, I'm going to notch a little bit up towards the optimism. So I am looking forward to 2025. You know, I know margins are pinched like they've never been before, but instead of these large shocks year over year about what was going on with DIR.

00:35:24:05 - 00:35:49:23

Todd Sega

You know it's low. But in terms of the percent change from what we've heard, it's at least stable from the past year. So at least knowing something's not going to be great allows you to plan for it. Which means it brings you a little bit more stability and what resources you may try to lock in. And so if you have a good set of fixed costs and great team members that are on more in the pharmacy, stay tuned. Look for those non dispensing opportunities, engage on them.

00:35:49:23 - 00:36:16:07

Todd Sega

If you do, more opportunities will spin the flywheel and more will come your way. So we can bend this needle and would love to make our biggest outcome measure, what percentage of all pharmacy revenues are coming from non dispensing and our measure of success, not just here but across the entire marketplace, will be when we get that number to be single, large single double digit and then cross the 50% mark,

00:36:16:12 - 00:36:29:11

Todd Sega

when we can say that we're helping to contribute and enable pharmacies to diversify their revenue model. So for that, I say we're making a really good step in 2025. We just need to lock arms and move forward so we can win together on that.

00:36:30:01 - 00:36:50:21

Nick Dorich

Yeah. And, Todd,I think that's the important aspect here for it is it's a it's a win together, consideration not just for, you know, for ourselves, here at PQS but for the pharmacies, for the health plans, but most ultimately is for the patients and how they are maximizing the care, the benefit that they get and working with their their local pharmacist and their pharmacy team.

00:36:50:23 - 00:37:12:17

Nick Dorich

So, Todd, appreciate you coming on to the show again. I think it's a pretty regular, probably annual, occurrence that we've got you back on the show. You and Jesse McCullough, probably the two most frequent guests that we've got on the show. And I always appreciate these opportunities for us to think ahead, to challenge ourselves and, and how we continue to push pharmacy forward.

00:37:12:19 - 00:37:26:15

Nick Dorich

And, you know, Todd, if there's folks who want to get information about what we're doing at PQS or hearing as you're sharing new information in 2025, can they find you on LinkedIn? Any other ways that they should look for these updates or get a hold of you?

00:37:26:20 - 00:37:44:14

Todd Sega

Yeah, sure. LinkedIn is always an easy way. It may not be as timely as this email from time to time, but yeah, LinkedIn is great. And then also reaching out directly on our website and using the support link there will help link me up, but would be happy to meet and chat with anybody and wish every everybody the best.

00:37:44:14 - 00:37:46:19

Todd Sega

And cheers to 2025.

00:37:46:19 - 00:38:07:18

Nick Dorich

All right, Todd, thanks for that. Final message there. We're looking forward to a great year ahead. And but for our listeners, for our watchers here on the show, that does mean we are at the end of today's episode, today's conversation. So thank you for joining us on today's episode of the Quality Corner Show. Before we close, we do have one final message from the PQS team.

00:38:07:18 - 00:38:11:21

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well.