As accessible healthcare providers, community pharmacies are key to the shift towards value-based care, which focuses on quality and cost-effectiveness in our U.S. healthcare system. Pharmacies and health plans need to adapt and work together to improve patient outcomes and reduce costs. Todd Sega, Managing Director of Pharmacy at PQS by Innovaccer, predicts five key changes that will drive pharmacy’s value-based care evolution in 2025.
1. Increased Non-Dispensing Revenue Opportunities
2025 is expected to deliver one of the largest increases in non-dispensing revenue opportunities for pharmacies. This shift is driven by several factors:
- A significant decrease in star ratings has prompted health plans to seek additional channels for improvement initiatives
- Health plans are exploring creative quality and clinical programs beyond traditional MTM services
- Unprecedented bonus pools are being created for pharmacies that can deliver value-based services, where some of the first true shared savings programs will be launched around managing drug formularies.
“We have seen a pretty big decrease in the star ratings for payers for the 2025 plan year,” notes Sega. “The percent of membership that’s in a four star or above contract is down 12% from the prior year… the impact on bonus payments to plans from the decrease can have a pretty big impact.”
2. Enhanced Pharmacy-Payer Partnerships
With greater opportunities come increased expectations. Health plans are implementing more rigorous evaluation of pharmacy performance:
“To whom much is given, much is expected,” Sega emphasizes. “We definitely see a lot more scrutiny by plans to say, ‘I really want to know what is it that providers, including pharmacists are doing'”
In 2025, health plans will use several deciding factors when evaluating program participation, success and expansion. Those factors will include:
- Enhanced documentation requirements for services provided
- Greater scrutiny of engagement levels and outcomes
- Potential emergence of high-performing networks
- Focus on pharmacies that can consistently deliver results
- Emphasis on true partnerships rather than broad network participation
3. Medicare Market Changes
Significant changes are hitting the Medicare landscape in 2025. As Sega explains: “These health plans that are terminating their Medicare line of business or have terminated some of their Medicare contracts for 2025; that’s going to displace about 1.4 to 1.5 million Medicare Advantage lives.”
The impact includes:
- Implementation of Inflation Reduction Act provisions
- Potential regional impacts on pharmacy reimbursement
- Changes in formulary requirements and benefit structures
- Increased need for patient education about insurance changes
Sega notes that pharmacies are usually on the front line when there are insurance adjudication challenges or cost barriers and these changes could likely create secondary impacts in the marketplace.
4. Team Based Care Approach
Success in value-based care requires a team-based approach and delegating a quality champion amongst a pharmacy team can reap benefits. “It certainly takes a team to win,” Sega emphasizes. “We’ve heard that directly from pharmacies where we check in and we see that they’re engaging and highly successful in some of our clinical and enhanced service programs.”
Key elements include:
- Designation of quality champions within the pharmacy
- Clear communication of goals and metrics across the entire staff
- Empowerment of pharmacy technicians to take on enhanced roles
- Visible tracking and sharing of performance metrics
- Structured delegation of responsibilities among team members
5. Workflow Solution Integration
The ability to seamlessly integrate value-based care activities into existing workflow will be crucial. “If you can’t help pharmacies operationalize what they need to do and when in workflow, it’s just a very, very steep gradient for pharmacies to have to push that boulder up the hill,” Sega explains.
Focus areas include:
- New technology solutions entering the market
- Focus on reducing manual processes
- Integration of clinical opportunities into daily workflow
- Tools to help prioritize high-value activities
- Solutions that enable team-based execution of services
Looking Ahead
Despite ongoing challenges with prescription reimbursement, the outlook for community pharmacy in 2025 appears promising. The stability in reimbursement (albeit low), combined with new revenue opportunities, creates a foundation for pharmacies to diversify their business models. Success will depend on pharmacies’ ability to embrace these changes, build effective teams, and leverage new workflow solutions.
“Look for those non-dispensing opportunities, engage on them,” Sega states. “If you do, it will help to spin the flywheel and more opportunities will be created.”
PQS will be launching a new product in 2025 that will allow pharmacies to focus on these non-dispensing opportunities to enable pharmacies to diversify their revenue model. More information will be available in the new year, and interested companies can reach out to PQS via the corporate website.
As the healthcare system continues its migration toward value-based care, pharmacies that adapt to these changes and capitalize on new opportunities will be best positioned for success in 2025 and beyond.