Unity Health Plans Insurance Corporation and Wisconsin Pharmacy Quality Collaborative Implementing Quality-based Pharmacy Services Reimbursement Problem Identification Reimbursement to community pharmacists has traditionally been based on the drug product, not the services provided. As reimbursement has decreased over time, pharmacies have had to make it up in volume by dispensing more prescriptions per pharmacist. The end result is less time to spend with patients. At the same time, payers have shown increased focus on quality of care as well as affordability of drug benefits. Wisconsin pharmacists have had opportunities to be compensated for cognitive services, but a lack of standardization among existing reimbursement models has limited participation. Objectives Restructure the financial relationships among payers and community pharmacies in a way that: 1) rewards professional services separately from dispensing, 2) establishes and raises quality standards, and 3) engages community pharmacies in keeping the drug benefit affordable. Target Audience Managed care plans and Wisconsin community pharmacists were the target audience of this initiative. Solution Unity Health Insurance participated in a collaboration of payers, community pharmacies and the Pharmacy Society of Wisconsin to develop and implement the Wisconsin Pharmacy Quality Collaborative (WPQC). The WPQC developed a credentialing process, training program and standardized professional services reimbursement schedule. Participating pharmacies implement changes within their practice sites to meet 12 "best-practice” quality-based requirements (such as having a medication error continuous quality improvement (CQI) process). Pharmacists complete training on the WPQC-required services and methods for integrating them into the pharmacy workflow. Pharmacies that meet the quality-based requirements are eligible for reimbursement from payers for providing value-added professional services to the payers’ members. Examples of reimbursed services include medication device teaching, adherence interventions, cost effectiveness interventions, facilitation of medication additions based on guidelines, and comprehensive medication reviews. Unity Health Insurance was the first payer to implement the WPQC program in March 2008, playing an integral role in advancing the project. Unity is a regional network model health maintenance organization providing prescription drug coverage for 42,000 individuals. The value-added pharmacy services were provided at no cost or copayment to Unity’s members. Results To date, 54 community pharmacies and more than 100 pharmacists are participating in WPQC. More than 120 pharmacists, six pharmacy technicians and 45 fourth-year University of Wisconsin—Madison School of Pharmacy students completing clerkships at WPQC pharmacies have been trained. A second payer joined the program in June 2008. In the first 18 months of the program pilot, 365 paid interventions were made on behalf of Unity Health Insurance members with an annualized calculated return on investment of 2.5 to 1. The calculated return on investment (ROI) was realized solely from the cost effectiveness interventions without regard to possible additional ROI from other types of interventions that are more difficult to quantify. The initial results of this program reveal that cost effectiveness interventions alone have paid for the entire program and support its continuation. In its pilot phase, WPQC served as one of Pharmacy Quality Alliance’s (PQA) five demonstration projects testing PQA quality measures. Two additional payers – a commercial plan insuring 700,000 members, and Wisconsin Medicaid – are expected to join WPQC in early 2010.