Pharmacy Insights: ECAPS, Market Access, Specialty Services, and Patient Care

The pharmacy industry is undergoing a significant transformation, driven by changes in legislation, market dynamics, and evolving patient needs. From the introduction of the Equitable Community Access to Pharmacist Services Act (ECAPS), which is expanding the scope of pharmacist services through Medicare reimbursement, to the growing complexity of specialty pharmacy services and the need to navigate market access strategies, pharmacies are at the forefront of reshaping healthcare delivery.

At the same time, improving the patient experience through easier payment processes is critical for enhancing patient satisfaction and pharmacy revenue. This article explores how these trends impact the pharmacy industry, their opportunities and challenges, and how pharmacies can adapt to continue providing valuable care while optimizing operations.

Supporting ECAPS: A New Era for Pharmacist Services

ECAPS is set to revolutionize the pharmacy landscape by expanding the role of pharmacists within the healthcare system. With bipartisan backing, ECAPS seeks to provide Medicare Part B reimbursement for low acuity clinical services provided by pharmacists, allowing pharmacies to move beyond their traditional dispensing role. This shift will improve patient access to essential care, particularly in underserved and rural areas, while enabling pharmacies to play a more integral role in the healthcare ecosystem and drive new revenue streams.

Benefits of ECAPS:

• Provides Medicare Part B reimbursement for select pharmacist services: ECAPS allows pharmacists to be reimbursed for various clinical services, including immunizations, medication therapy management (MTM), chronic disease management, and certain diagnostic tests. This reimbursement structure helps pharmacists generate revenue from services beyond dispensing medications, contributing to improved financial sustainability.
• Shifts the business model from dispensing to clinical services: Traditionally focused on filling prescriptions, pharmacies will now be compensated for their involvement in patient care management. This shift allows pharmacies to adopt a more proactive role in preventing and managing chronic conditions, offering consultations, and optimizing medication regimens for better patient outcomes.
• Expands access to essential services for patients: ECAPS provides greater access to healthcare services, especially in rural or underserved areas where patients may have limited access to primary care providers. By leveraging pharmacists’ expertise, patients can receive vital services such as immunizations, health screenings, and chronic disease management at their local pharmacy.

Market Access Strategies: Navigating Payor Trends

As ECAPS begins to reshape the pharmacy industry, understanding and navigating payor trends will be essential for pharmacies to thrive. In a rapidly changing healthcare landscape, staying ahead of evolving payor requirements and securing favorable contracts can significantly impact a pharmacy’s financial performance. Implementing effective market access strategies will help pharmacies optimize reimbursement, minimize financial risk, and ensure they can continue to provide high-quality care to patients.

Key Strategies:

• Securing contracts with payors: Building strong payor relationships is vital for securing reimbursement for pharmacy services. Pharmacies must focus on negotiating favorable contract terms, including reimbursement rates for clinical services like MTM and chronic disease management. Developing an understanding of the different payor requirements and how to meet them is crucial for sustaining business growth.
• Optimizing reimbursement processes: To ensure timely and accurate reimbursement, pharmacies need to adopt efficient processes for claims submission, denial management, and payment tracking. Utilizing technology to streamline billing workflows and integrate pharmacy management systems with payor networks can reduce administrative overhead, improve cash flow, and enhance revenue cycle management.
• Staying ahead of evolving payor requirements: Payor policies are constantly evolving. Pharmacies must monitor changes in payor requirements and clinical guidelines to ensure they remain compliant and continue to receive the appropriate reimbursement for their services.

The pharmacy scope of services is expanding, and legislation and reimbursement structures are driving further growth. As of October 2024, 43 states have mandated at least one reimbursable pharmacy service through their state Medicaid program, and this trend is expected to grow in 2025, providing pharmacies with more opportunities to deliver and get reimbursed for clinical services.

Specialty Pharmacy: Evolution and Opportunities

Specialty pharmacy services, which involve high-cost, complex medications for conditions like cancer, HIV, and autoimmune diseases, are undergoing significant changes. One of the most notable developments is the transition of these services toward the medical benefit pathway, where specialty drugs are reimbursed under the medical insurance benefit rather than the pharmacy benefit. This shift presents challenges and opportunities for pharmacies, as it requires navigating more complex billing systems and adjusting to changing reimbursement models.

Factors Driving Transition:

• Increasing complexity and cost of specialty medications: As specialty medications become more advanced and costly, payors look for ways to control utilization and ensure that these drugs are used appropriately.
• Moving specialty drugs to the medical benefit to exert greater control over utilization: By shifting specialty medications to the medical benefit, payors can more closely manage the utilization of these drugs, ensuring they are prescribed and administered in line with clinical guidelines. This can lead to tighter formulary restrictions, prior authorizations, and higher administrative burdens for pharmacies, which must adjust to new billing processes.
• Mitigating perceived risks of waste: Specialty drugs are expensive, and their administration often involves complex therapy regimens that can result in medication waste if not effectively managed. The move to the medical benefit pathway allows payors to better monitor drug use and minimize waste, improving cost management.

As these transitions unfold, automation and system integration are critical for pharmacies to manage the operational complexities that arise. Pharmacies must invest in technology to streamline clinical documentation, denial management, and reimbursement processes, helping to ensure that specialty medications are administered appropriately and reimbursed accurately.

Patient Experience Pivot: Enhancing Care at the Point of Service

Amidst these pharmacy industry trends, making patient payments easier can significantly benefit both pharmacies and patients. By providing accurate out-of-pocket expense estimates during the first patient encounter, pharmacies can streamline payment collection and enhance revenue and patient satisfaction. Tools like patient out-of-pocket estimators help prevent surprise costs and mirror traditional pharmacy experiences, offering transparency and ease for patients while ensuring smoother financial interactions for pharmacies.

Making Patient Payments Easier Benefits Pharmacies and Patients:

• Simplified Payment Processes: Reducing barriers to payment helps patients access the medications and clinical services they need, improving their experience and treatment outcomes
• Increased Convenience for Patients: Clear, upfront payment expectations help patients feel more confident about meeting their financial obligations
• Better Adherence to Treatment Plans: When payment is easy and predictable, patients are more likely to stay on track with their medications and clinical services, improving their health outcomes
• Boosted Financial Performance for Pharmacies: Streamlined payment processes increase cash flow and reduce the time spent on collections, enhancing the bottom line
• Enhanced Customer Satisfaction and Loyalty: Patients appreciate the transparency and ease of paying for services, leading to greater trust and repeat business
• Allowing Pharmacies to Focus on Care: With the financial side taken care of efficiently, pharmacies can focus more on delivering high-quality care and managing clinical workflows effectively

Enhancing Patient Access and Driving Revenue Growth Through Streamlined Patient Payments

Pharmacies are uniquely positioned to address healthcare access issues, with 48% of the U.S. population living within one mile of a community pharmacy. As pharmacies take on more clinical roles, such as monitoring treatments and providing patient counseling, simplifying payment processes improves operational efficiency and enhances the overall patient experience.

As pharmacies expand their offerings, challenges and questions abound. Watch our on-demand webinar to learn what our panelists from The Kroger Co. and Blue Cross and Blue Shield of North Carolina, among others, have to say about Forging the Future of Pharmacy.