Recently, I came across an interesting pharmacy reimbursement model introduced by Sunflower Health Plan in Kansas.1 Sunflower Health Plan is a managed care subsidiary of the Centene Corporation, St. Louis, MO.2 Sunflower will offer a higher dispensing fee for claims submitted from pharmacies that have achieved accreditation through the Center for Pharmacy Practice Accreditation (CPPA). I was pleased to see that this is truly an increased fee, and not a redistribution of claim withholds, which pharmacies are experiencing with some plans today.
Pharmacy Practice Accreditation
Previously unfamiliar with CPPA, I discovered that the organization is a union created by the American Pharmacists Association, National Association of Boards of Pharmacy, and American Society of Health-System Pharmacists to supervise pharmacy practice site accreditation.3 Through accreditation of pharmacy practices, their mission is to work for the public and raise the level of pharmacy-delivered patient care services. My interpretation is that Sunflower Health Plan values the additional services provided by accredited pharmacies; they view the additional dispensing fee as an investment that will lead to better health outcomes, and presumably lower healthcare costs overall. It is gratifying that Sunflower Health Plan sees value in the services that pharmacies provide, and that they contribute to overall management of healthcare costs.
Most pharmacy networks today have basic credentialing, with minimum standards that need to be met. The default qualification for network participation is a pharmacy license in good standing with the State Board of Pharmacy in the state where the pharmacy is located.4 This CPPA process builds on these standards, creating a higher-caliber network. This will be an interesting experiment by the Sunflower Health Plan. How many pharmacies in Kansas are accredited to participate? Will the increased dispensing fee drive pharmacies to seek accreditation? According to the CPPA website, no Kansas pharmacies are currently CPPA-accredited.5
Accreditation and the Future of Pharmacy
Will Sunflower Health Plan be able to measure improved outcomes in patients who frequent a CPPA pharmacy? Is this a road map to help drive quality? Will this be the beginning of a trend?
One could argue that this is simply an extra cost that pharmacies need to incur to demonstrate competency. If this accreditation gains sufficient traction, will pharmacies feel a need to achieve accreditation for fear of being excluded, even though participation is voluntary today? Is there a guarantee that incentive fees will continue and not be discontinued after pharmacies have invested time and money into the accreditation process? Could this lead to pharmacist competency assessments in the future?
As you can see, I have mixed emotions about an incentivized dispensing fee connected to pharmacy accreditation. On one hand, I am pleased to see the program is truly an additional payment versus redistribution of a pharmacy withhold payment. On the other hand, is this a sugar-coated approach to introducing additional regulations and requirements for pharmacies and pharmacists?
- Centene Corporation. Sunflower Health Plan CPPA accreditation. www.sunflowerhealthplan.com/providers/pharmacy/cppa-accreditation.html. Accessed July 20, 2016.
- Centene Corporation. Contact. www.centene.com/contact. Accessed July 18, 2016.
- Center for Pharmacy Practice Accreditation. About. www.pharmacypracticeaccredit.org/about. Accessed July 18, 2016.
- OptumRx. OptumRx provider manual: 11th edition. http://learn.optumrx.com/microsite/assets/pdf/210.pdf. Accessed July 20, 2016.
- Center for Pharmacy Practice Accreditation. Community pharmacy practice accreditations. www.pharmacypracticeaccredit.org/practices. Accessed July 18, 2016.