AMCP Pay-for-Performance Principles: Performance-Based Reimbursement and Direct and Indirect Remuneration (DIR) Fees

Abstract

Health care services provided by pharmacists are a vital part of comprehensive patient care. AMCP supports the use of payment arrangements for pharmacists that include performance- based metrics related to these health care services, on which some of the pharmacist's reimbursement is based. At the direction of its Board of Directors, the AMCP Public Policy and Professional Practice committees developed the following principles for pay-for-performance to promote the use of these arrangements that lead to improved patient outcomes: 1. Measures used in pharmacy payfor- performance contracts must be fair, attainable, meaningful, and applicable to the pharmacy type being evaluated and the patient populations being served. 2. The Medicare Part D program should adopt a core set of standardized pharmacy performance measures based on consensus and input from pharmacy providers, pharmacy benefit managers, health plans, and other pharmacy stakeholders, while allowing plan sponsors the flexibility to utilize additional measures that are reported to CMS. 3. Pharmacy performance measures must recognize and respond to issues of health equity and socioeconomic disparities by benchmarking performance based on size, geography, and patient demographics. 4. A fair and meaningful performancebased contract will be transparent, with clear and concise provisions that are available and accessible to all participants in advance of any performance measurement period. 5. Prior to the development of a standard measure set, the specifications of the measures included in a contract must be unambiguously defined. 6. The organizational level at which metrics will be calculated and compared under a performancebased agreement must be precisely defined in the contract. 7. Participants in pharmacy performance- based contracts must agree upon a plan for collecting, integrating, and analyzing the data needed to meet contract requirements, including identifying who will be responsible for the analysis and who will pay for these tasks. 8. Adjusting pharmacy reimbursement systems to compensate pharmacies for the needed investments in data reporting infrastructure required to meet performance-based contract requirements should be considered. 9. Performance-based price concessions are an important and necessary component of pay-forperformance programs. 10. Fees calculated based on pharmacy performance on agreed upon measures should be based on known, fixed metrics. 11. Price concessions should never be structured as a "claw back," where payment for a prescription product may be owed from the pharmacy to the payer. This should not be confused with the appropriate use of financial withholds or recoupments in performance-based arrangements. 12. Performance-based reconciliation reporting should be completed no later than 90 days post-plan year to allow parties to meet contractual obligations. 13. Preferred pharmacy networks are a vital tool for lowering patient costs and improving quality and outcomes.