How Pharmacists Can Generate Non-PBM Revenue with Care Management

Several factors, including supply chain costs and competitive pressures, make it harder for independent pharmacies to realize profits and growth. From 2016-2022, the average independent pharmacy gross profit margin was 20.8% to 21.1%. 

The good news is that the pharmacist's role has been expanding since the COVID-19 pandemic, when pharmacists administered 45% of all vaccines. In fact, pharmacist-led interventions averted millions of COVID-19 deaths and hospitalizations. It’s estimated that healthcare saved over $450 billion because pharmacies relieved significant strain.

As pharmacists realize increased licensing authorities and move toward becoming recognized providers by Medicare, launching a collaborative care management program with physicians offers reliable, non-PBM revenue sources. This can set pharmacies up for more expansive partnerships, contracting, and value-based care.

Pharmacists are trusted to provide for patients and fill care gaps.

• 85% of pharmacists see their role expanding to preventive care and care management team integration
• 63.4% of physicians see pharmacists playing a greater role in preventive care
• More than 50% of patients are comfortable with pharmacists checking vital signs, diagnosing, and prescribing for acute conditions 

Source: The Prescription of Trust report, 2022.

Pharmacists can leverage care management to drive revenue

Generating non-PBM revenue through care management enables pharmacists to partner with providers. This remunerates both for many of the activities they’re already carrying out while enhancing care and outcomes for senior adults with chronic conditions.

Pharmacists have the statutory authority to work with physicians to manage patients' chronic illnesses and provide preventive care through care management programs. These include Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Annual Wellness Visits (AWV), and Transitional Care Management (TCM).

For example, CCM can provide critically needed services to patients and a sustainable, profitable revenue stream for pharmacists and providers. Research studies have shown that CCM programs can yield a profit, reporting upwards of 27.8% ROI.

Estimating potential care management revenue

Pharmacists can work with providers to conduct an economic analysis and estimate revenue targets as part of an initial pilot, a second cohort, or when scaling an existing care management program.

Depending on your patient population analysis, a pilot could start with 25 patients, a second cohort could ramp up to 75-100 patients, and, ultimately, scale to 250 patients per pharmacy team member. 

If an organization has the capacity, multiple care team resources could be employed, which could increase the number of patients enrolled by two- or three-fold.

Here’s a formula for estimating the total potential revenue of an example program:

Successful care management programs could also see additional downstream revenue. Other services or assessments could factor into care management activities and have claim to added reimbursement. For example, enrolled patients may also pursue an Annual Wellness Visit.

Four ways ThoroughCare enables pharmacist-delivered care management

Creating a successful care management program requires several components, including: 

• Assessing the program’s potential economic value 
• Partnering with a provider who can bill for care management services
• Having the operational structure and workflow tools to ensure smooth patient care and team collaboration

ThoroughCare eases the hurdles to starting, running, and managing profitable care management programs in collaboration with provider organizations. 

Operational workflow and patient population management

Adding a new service requires establishing program standards and workflow. 

ThoroughCare provides everything needed to implement a care management program and integrated, evidence-based workflow. 

The patient dashboard displays critical aspects of the program, including significant benchmarks, performance metrics, goals, conditions, and pending activities. 

Patient management is streamlined through task lists, quick filters, and status indicators.

Clinical support and evidence-based tools and content

Guided clinical assessments streamline operations and enable meaningful patient-facing conversations.

These assessments leverage motivational interviewing techniques and SMART goal setting to create a personalized care plan. Pharmacists share, or collaborate, on the plan with the overseeing provider and track patient progress toward health objectives.

Plus, clinically sound and unbiased health information is readily accessible through our integration with Healthwise. Pharmacists are equipped with reliable, easy-to-understand educational materials that match how patients learn, or use, research to offer ad hoc, clinical education guidance.

Collaborative communication, documentation, and reporting

Clinician-friendly dashboards can be visible to the pharmacist, physician, and their care team, keeping everyone updated. 

Additionally, sophisticated analytic capabilities allow the pharmacist or physician to organize and filter patient and organizational data to inform program oversight and management. Interactive reports, visualization tools, and real-time analysis help physicians and providers turn insight into action.

Lastly, robust reporting capabilities support collaboration and transparency that build confidence across both healthcare organizations.

Billing reporting and documentation

Powerful time tracking, monitoring, and alerting features ensure that the pharmacist and provider use monthly patient contact time wisely and reach billable time requirements. 

ThoroughCare automatically tracks and assigns CPT codes to simplify claim submission, which can help offset costly DIR fees.

Additionally, the software demystifies care management reimbursements, making documentation and reporting for billing quick and simple. 

*Reimbursement rates are based on a national average and may vary depending on your location. 

Check the Physician Fee Schedule for the latest information.