This document discusses strategies for improving patient medication adherence in order to increase adherence metrics and reduce DIR fees. It begins by explaining that DIR fees have become a significant economic burden for pharmacies. It then provides tips for pharmacies to improve adherence, such as creating an EQuIPP account to track scores, focusing on adherence metrics like PDC, implementing medication synchronization programs, and educating patients on adherence. The document also discusses how the beginning of the year is important for adherence since DIR fees are calculated based on patient compliance and a patient's first fill starts the clock for the year. It suggests counseling, synchronization programs, reminder calls/texts, and compliance packaging as next steps for working with non-adherent patients.

1. Retail Services Group “Mentor”
“Focus On The Business Model”
INTRODUCTION
The access, pricing and reimbursement landscape is rapidly
evolving as independent pharmacy shift to a value-based
healthcare system. This transition coupled with increasing drug
pricing reductions through retroactive (Clawback) of that drug
pricing has undermined the ability of the pharmacy owners and
managers to project cash flow and profitability.

2. WHAT CAN YOU DO TO INCREASE ADHERENCE METRICS?
 Create an account on EQuIPP.org.
 Review your EQuIPP scores monthly, new data is released on the 15th of every
month.
 Focus on improving adherence metrics.
 Implement and optimize your pharmacy’s medication synchronization program.
 Improve your will call process. If a Rx isn’t picked up, what is the next step?
 Educate your patients on the importance of adherence.
 Make sure you and your team understand the role everyone plays when it comes
to improving EQuIPP Scores and Star Ratings.

3. PBM PLAN DIRB DIRG
CAREMARK SILVER SCRIPT PART D PREFERRED NONPREFERRED PREFERRED NONPREFERRED
CAREMARK 2020 9.50% 7.50% 12.00% 10.00%
CAREMARK 2019 7.00% 5.00% 8.50% 6.50%
CAREMARK WELLCARE MEDICARE PART D
CAREMARK 2020 9.50% 7.50% 12.00% 10.00%
CAREMARK 2019 7.00% 5.00% 8.50% 6.50%
EXPRESS SCRIPTS EXPRESS SCRIPTS PART D
EXPRESS SCRIPTS 2020 AWP-19.25% $0.40 $7.57 $7.57
EXPRESS SCRIPTS 2019 AWP-16% $0.40 $6.88 $6.88
MAJELLAN EXPRESS SCRIPTS PART D
MAJELLAN 2020 5.00% 3.00% 5.00% 3.00%
MAJELLAN 2019 AWP-16% $0.40 5.00% 3.00%
OPTUM CIGNA PART D
OPTUM 2020 9.00% 9.00% 9.00% 9.00%
OPTUM 2019 9.00% 9.00% 9.00% 9.00%
OPTUM PRES.SOL. PART-D
OPTUM 2020 10.00% 10.00% 10.00% 10.00%
OPTUM 2019 10.00% 10.00% 10.00% 10.00%
MEDICARE CROSSWALK
DIR

4. Definitions
CMR(ComprehensiveMedicationReview): CMRisaninteractive,person-to-personortelehealthmedicationreviewandconsultationofabeneficiary’s
medications(includingprescriptions,over-the-counter(OTC)medications,herbaltherapies,anddietarysupplements)byapharmacistorqualifiedprovider
thatisintendedtoaidinassessingmedicationtherapyandoptimizingpatientoutcomes.
DIR(DirectandIndirectRemuneration): ApriceconcessionintheformofanetworktoplanrebatethatisusedbyPlanSponsorstoreducecostorcreate
betterhealthprogramsforPartDbeneficiaries. OftenreferredtoasavariableDIR,wherethenetworktoplanrebateisbasedondifferentoperationaland
clinicalcriteria. GenerallybetterperformanceequalsalowerDIR.
EQuIPP(ElectronicQualityImprovementPlatformforPlans&Pharmacies): Aperformanceinformationmanagementplatformthatmakesunbiased,
benchmarkedperformancedataavailabletobothhealthplansandcommunitypharmacyorganizations.
GDR(GenericDispensingRate):Proportionofallprescriptionsdispensedasgeneric.
GER(GenericEffectiveRate):AveragepercentdiscountoffoftheAWPforallgenericdrugs,whetherreimbursedatMAC,UsualandCustomary,orAWP
discount.

10. DRUG CHANNEL.COM (ADAM FEIN,PhD)
Pharmacy DIR Fees Hit a Record $9 Billion in 2019—That’s 18% of Total
Medicare Part D Rebates
Pharmacy-related price concessions in Medicare Part D—known as pharmacy
DIR fees--have grown faster than most people realize. We estimate that these
payments reached $9.1 billion in 2019. This figure indicates that about 18% of
total Medicare Part D rebates are now paid by pharmacies, not manufacturers.
To address concerns about how these fees are computed, the Centers for
Medicare & Medicaid Services (CMS) has proposed some minimal transparency
requirements for monitoring the metrics behind DIR fees. I suspect that the
proposal will have no near-term impact on slowing the growth trends.
Our long-time readers know that I’ve been skeptical about pharmacy owners’
claims regarding the impact of DIR fees. But it does now appear that these
payments have become a significant economic burden. When the facts change, I
change my mind. What do you do?

11.  ALL MEDICARE PART D PLANS ARE NOT BASED PSAO
PLAN PERFORMANCE.
 FOR EXAMPLE, CAREMARK MEDICARE PART D PLANS
ARE DIRECT CONTRACT THAT MEASURE PDC
PERFORMANCE ON PHARMACY.
 HUMANA IS ANOTHER DIRECT CONTRACT PLAN BASED
UPON PHARMACY PERFORMANCE.
PLAN VS PSAO

12. QUESTION: WHAT ARE DIR FEES?
https://www.cms.gov/newsroom/fact-sheets/medicare-part-d-direct-and-indirect-remuneration-dir
AND, HOW DO THEY AFFECT MY
PROFITABILITY AND BUSINESS
PRODUCTIVITY?

13. DISCUSSION ON DIR FEES
QUESTION: WHAT ARE DIR FEES AND HOW DO THEY AFFECT MY
PROFITABILITY AND BUSINESS PRODUCTIVITY?
ANSWER: THE PROFITABLITY BENCHMARK % DIR$/GM$ (Actual $ DIR Fees
/ Actual GM $) DETERMINES THE SHRINKAGE OF GM$ BEFORE COVERAGE
OF TOTAL EXPENSES AS A RESULT OF DIR FEES.
2020 RX/DAY 2020 % DIR$/GM$
96 9.98%
163 11.19%
230 13.65%
THE NATIONAL AVERAGE IS APPROXIMATELY 10%. THE % WILL VARY BY
BRAND $ VS GENERICS $.

14. PATIENT ADHERENCE
by RETAIL SERVICES GROUP

15. PATIENT
ADHERENCE
WHY?

16. PATIENT
ADHERENCE
WHY?
A study published in Medical Care found that if one-quarter of hypertension patients who were
non-adherent became adherent, Medicare could save nearly $14 billion annually — preventing
more than 100,000 emergency room visits and 7 million inpatient hospital days.

17. PATIENT
ADHERENCE
WHY?
Engaging Patients to Optimize Medication Adherence
Medication adherence is a significant public health challenge. As each patient is unique, it is critical for health
care systems and providers to better characterize and meet individual patient needs at each stage along the
way in order to improve medication adherence and ultimately improve patient well-being.

19. COMPLIANCE STRATEGIES THROUGH DELIVERY
Packaging interventions to increase
medication adherence: systematic
review and meta-analysis

20. COMPLIANCE STRATEGIES THROUGH DELIVERY
Inadequate medication adherence is a widespread problem
that contributes to increase chronic disease complications and
health care expenditures. Packaging interventions using pill
boxes and blister packs have been widely recommended to
address the medication adherence issue. This meta-analysis
review determined the overall effect of packaging
interventions on medication adherence and health outcomes.
In addition, we tested whether effects vary depending on
intervention, sample, and design characteristics.

21. COMPLIANCE STRATEGIES THROUGH DELIVERY
We found using moderator analyses that interventions were most effective when
they used blister packs and were delivered in pharmacies.

22. AGENDA
• 2020 ADHERENCE: WHY IS THE FIRST PART OF THE YEAR SO
IMPORTANT?
• IDENTIFYING NON-ADHERENT PATIENTS
• NEXT STEPS IN IMPACTING ADHERENCE

23. WHAT IS PDC? Proportion of Days Covered.
 PDC measures adherence as the percentage of Medicare
Part D beneficiaries whose prescription claims indicate
that patients have sufficient medication on hand to
cover 80% or more of the period during which they are
supposed to be taking the medication. (CMS does not
assign star ratings to pharmacies.)
 Pharmacies can influence such metrics as the
Proportion of Days Covered, which measures adherence
for:
 Oral Diabetes
 Statins
 Hypertension

24. AGENDA
• 2020 Adherence- Why Is The beginning of the year so
Important?
• Identifying Non-Adherent Patients
• Next Steps in Impacting Patients

25. Where do we go
from here?

28. I’VE IDENTIFIED
NON-ADHERENT PATIENTS.
What do I do next?
• ADHERENCE COUNSELING
• MEDICATION SYNCHRONIZATION
PROGRAMS
• REMINDER CALLS AND TEXTS
• DELIVER MEDICATIONS
• COMPLIANCE PACKAGING

29. 2020 Adherence
1. DIR FEES ARE CALCULATED BY PATIENT COMPLIANCE
2. A PATIENT’S FIRST FILL OF THE YEAR BEGINS THE “clock”
3. IF A PATIENT FILLS THEIR MEDICATION FIRST TIME ON JANUARY 1;
THEY CAN MISS A TOTAL OF 73 DAYS THROUGHOUT THE REST
YEAR TO BE CONSIDERED “COMPLIANT”.

30. MEDICARE PART D
CONVERT COPAY TO CASH

31. QUESTIONS???