Analyzing the Costs of Outsourcing Clinical Pharmacy Services


It is no secret that providing quality clinical pharmacy services often comes with a high cost for health plans. 

However, medication-related services – like comprehensive medication management (CMM) – impact nearly 50% of Medicare Star Rating categories.  This is due, in large part, to the multiple studies that show how CMM and related services help patients manage chronic diseases (e.g. diabetes, hypertension).

Conversely, effectively providing clinical pharmacy services often comes with a high price tag. And frequently, the tradeoff comes down to the quality of care and profitability of the program. Often, health plans are left wondering whether providing clinical pharmacy services is financially feasible. 

Ultimately, the decision requires a thorough cost analysis before deciding whether the services should be built and delivered in-house or outsourced to a trusted partner. When making this decision, it’s vital to consider the larger impact on quality improvement measures, including Star Ratings.   

Star Ratings

The Star Rating system was introduced more than a decade ago as a way for CMS and consumers to compare different health plans based upon metrics other than cost. A Star Rating is reported for each individual component of a health plan. A five-star rating shows that a health plan delivers exceptional member care and has high member satisfaction. 

A health plan Star Rating goes up and down, depending on the quality of the services provided. According to studies, failure to complete comprehensive medication reviews (CMRs) or improve CMM metrics can significantly reduce Star Ratings. Achieving a five-star rating in all three categories – Medicare Advantage, Part D, and Overall Care – is extremely difficult to achieve with in-house resources, even in the best-staffed health plans. 

Member enrollment & bonus payments

Health plan ratings are measured in nine different categories:

  1. How many members comply with preventive care and screening recommendations.
  2. What the health plan does to help with chronic condition management.
  3. How responsive the plan is, what’s the users’ access to care, and overall quality.
  4. The number of complaints and appeals health plan gets.
  5. Health plan customer service.
  6. Medication plan customer service.
  7. Member complaints and changes in the medication plan’s performance.
  8. Member experience with the medication plan.
  9. Accuracy and clarity of prescription drug information as well as pricing.

Star Ratings will affect a plan’s member enrollment numbers. The logic behind this is simple: if a health plan doesn’t maintain a high rating, other potential members will choose a better-performing option. If a plan begins to see a decline in members, they’ll begin to lose money in more ways than one. 

CMS Star Ratings are a way for healthcare payers to get bonus funding, based on more than 50 criteria that derive from quality measures like HEDIS. If a plan has a rating with a minimum of three stars, it will be eligible for bonus payments at the end of the year. However, if the plan has a Star Rating below three, it can potentially get flagged for termination. 

CMR completion rate

A comprehensive medication review – or CMR for short – gives pharmacists an opportunity to perform clinical services for health plan members. However, due to time constraints related to retail pharmacy environments, most pharmacists can’t perform CMRs. 

Unsurprisingly, a low CMR completion rate can have an impact on the Star Rating of a plan. The Centers for Medicare & Medicaid Services now include CMR completion for patients as an element of the overall Star Rating system. 

One way to affect the CMR completion rate is to incorporate additional staff, including pharmacists, into the workflow. In a recent study, a team of pharmacists was able to increase the number of completed CMRs from 29 to 158 by adding staff members.

Balancing the costs and benefits of virtual care

One silver lining of the COVID-19 pandemic was the rapid adoption of telemedicine services by healthcare consumers. For patients, telemedicine services have become a convenient way to connect with their healthcare provider. And for healthcare providers, telemedicine technology has enabled practices to increase the population they can serve and the speed at which they can serve them.

It’s not a stretch to see how similar technologies can be used to deliver clinical pharmacy services. Ultimately, the question is whether the investment in this technology would increase profitability. While the exact “profitability” may be hard to measure, there are clear benefits.

First, if health plan members enjoy their experience receiving clinical pharmacy services virtually with a pharmacist matched to them, it will have a positive effect on the Star Rating and, in turn, a positive effect on the profitability of the program. 

Additionally, technology can enable more touchpoints between members and pharmacists, leading to improved medication adherence rates. This leads to fewer emergency room visits, decreased healthcare costs, and an improved relationship with their pharmacist and health plan. 

Often, medication non-adherence occurs because members don’t have someone consistently monitoring and advising them on their prescriptions and medication regimens.

There are two primary areas where telemedicine technology can significantly improve the quality of the relationship between member and provider – diversity and area of expertise

Member diversity 

Not speaking a patient’s native language can be a tremendous barrier for pharmacists looking to establish a long-lasting relationship and build trust.

For example, more than 20% of people in the United States speak a language other than English in their households. For this reason, health plans need to bear in mind that up to a fifth of their members are not native English speakers. 

By leveraging modern technology such as Aspen RxHealth, health plans can take spoken language into consideration when matching members to pharmacists.

Specialist pharmacist

Just like matching on the criteria of language, Aspen RxHealth’s platform also matches pharmacists with patients based on a multitude of often overlooked criteria, including geographic location and medical conditions.

Every patient is unique, as is every pharmacist. Finding a trusted partner who has built the technology to foster longitudinal relationships between patients

and pharmacists are paramount to positively impacting health outcomes while increasing patient-pharmacist satisfaction.

In conclusion

Keeping everything in-house has certain benefits. However, outsourcing clinical pharmacy services can help health plans keep costs low, member satisfaction and outcomes positive, and Star Ratings high.

Beyond the immediate financial and health benefits, outsourcing clinical pharmacy services to the right partner can help create and maintain long-term relationships with health plan members. 

The flexible nature of outsourcing enables health plans to design unique engagement strategies for members while taking on less risk and improving outcomes.

Explore all the solutions Aspen RxHealth can provide as your clinical pharmacy services partner.