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Canadian Pharmacists Association
Canadian Pharmacists Association
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Pharmacy Outcomes Based Reimbursement Principles

Pharmacists and pharmacies in Canada practice to the highest standards of care. They are increasingly delivering new and innovative services that ensure patients get the most out of their medications and stay healthy in their communities.

In recent years, public and private payers have started to explore options geared towards outcomes- based reimbursement models. Pay for performance is one such model that has been introduced in other jurisdictions and most recently, in the Canadian community pharmacy landscape. While pharmacy recognizes the need for innovation in pharmacy reimbursement and the desire for payors, both public and private, to introduce new payment models, such initiatives must respect pharmacists’ professional autonomy to practice in the best interest of patient health and safety. Above all, any new program must be designed to target outcomes with proven benefits to patients.

After evaluating the evidence and benefits of pay for performance initiatives in other areas of healthcare around the world as well as the impact of these initiatives on patient outcomes and pharmacy practice, pharmacy has developed a list of program and measure principles that need to be followed in the development of any new pay for performance programs in Canada. These include:

Program

Harmonized design

  • Key program features must be harmonized and consolidated across all payors to make the implementation manageable at the pharmacy level
  • Program must be created in collaboration with Canadian industry stakeholders including pharmacists, patients, prescribers, payors, associations, pharmacy owners, regulators and CQI experts

Supports patient-pharmacist-prescriber relationship

  • Program must include an incentive component for patients and prescribers as well as pharmacists to improve collaboration and patient outcomes

Cost of implementation is minimized

  • The implementation of the program must not impose a financial burden on pharmacies and pharmacists
  • Incentives must provide adequate margins to cover costs to implement the program
  • Access to comprehensive and fully transparent data needed to achieve and validate results must be facilitated by payors
  • Any systems or platform needed to measure and achieve results must be provided by payors, at no cost to pharmacy and pharmacists

Reimbursement is positive not punitive

  • Participation in the program must not result in a reduction of reimbursement for the current dispensing process and should be entirely independent of dispensing reimbursement
  • The reimbursement model must be transparent and predictable
  • Funding for reimbursement of the program should come from a portion of savings accrued from improving health outcomes rather than shifting revenue from low performers
  • Reimbursement must cover the cost of implementation by pharmacies and provide sufficient incentives to impact practice

Should not create perverse incentives

  • Program design should not create incentives that could lead to deselecting of certain patients
  • Opportunities to improve program design should be continuously evaluated and thoroughly considered to prevent unintended consequences

Measures

Evidence-based to improve patient health outcomes

  • Measures must be anchored in valid and reliable evidence and reviewed regularly

Achievable

  • Measures must be achievable and within pharmacists’ influence and control
  • There should also be the ability to remove patients from being assessed if pharmacists record unsuccessful attempts to make recommendations to patients, if prescribers disagree with recommendations, or if recommendations are inappropriate for patients due to comorbidities or other factors

Transparent

  • Details on specific inclusion and exclusion criteria and algorithms around measures should be made public

Risk-Adjusted

  • There is a need to adjust for risk if comparing performance of pharmacies to one another to take into account variations in practice setting, social, economic, cultural factors as well as patient population comorbidities and disease severity

Download PDF — Pharmacy Outcomes Based Reimbursement Principles