Measurement and Reporting: Proving Value in VBC (Quality, Utilization, Cost)

Source Overview

This article is compiled from the broader VBC resource document and is intended to stand alone for this topic.

Core Principles and Objectives of Value-Based Care

At its heart, value-based care seeks to maximize the value patients receive from healthcare. Value is commonly defined as the quality of care (outcomes, safety, service) relative to the cost of care over time[4]. In practice, this means focusing on:

• High-Quality Outcomes: Ensuring treatments are effective, safe, and evidence-based. The National Academy of Medicine’s STEEEP framework summarizes high-value care as Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered[1]. For example, helping a diabetic patient achieve good blood sugar control with minimal side effects is high-value care, whereas poor control or avoidable complications signal low value.

• Patient Experience and Engagement: Improving the patient’s experience of care and satisfaction. VBC emphasizes person-centered care – care that is coordinated around patient needs and preferences[5][6]. This could mean better care coordination so patients don’t feel lost in the system, or involving patients in shared decision-making about their treatments.

• Cost Efficiency: Reducing unnecessary spending by avoiding waste, preventing hospitalizations, and eliminating services that don’t add value. For instance, ensuring medication regimens are optimized can prevent costly adverse events or admissions. Lowering the total cost of care per patient is a key objective, alongside maintaining or improving outcomes[4].

These elements correspond to the Triple Aim: (1) improve population health outcomes, (2) enhance the patient experience, and (3) reduce per-capita costs[1]. In VBC models, providers are rewarded for performance on these dimensions rather than volume of services. Metrics might include clinical indicators (e.g. blood pressure control rates), utilization measures (e.g. hospital readmission rates), and patient satisfaction scores. The ultimate mission of VBC is to align incentives so that what’s best for the patient’s health is also best for the providers’ reimbursement. This alignment encourages proactive, preventive care and better care coordination. Providers (including pharmacists) are prompted to minimize low-value or harmful interventions and focus on high-value activities that keep patients healthy[7].

In summary, the core principles of VBC revolve around “quality over quantity”: delivering better outcomes, better experiences, at lower cost. Pharmacies, with their frequent patient interactions and medication expertise, are uniquely positioned to contribute to these goals by enhancing medication safety, adherence, preventive care, and chronic disease management in the community[3].

Structural and Operational Challenges for Pharmacies in VBC

While the opportunities are significant, pharmacies face a number of challenges and barriers when engaging in value-based care models. Transitioning from a volume-driven model to a value-driven one is not trivial. Key challenges include:

1. Reimbursement and Provider Status: Perhaps the biggest structural challenge is that pharmacists are not universally recognized as healthcare providers for reimbursement under federal law (Medicare). This means they often cannot directly bill Medicare for services (other than limited cases like MTM under Part D or incident-to physician billing). As a result, securing payment for pharmacy clinical services can be cumbersome. Pharmacies may need to partner with a billing provider (physician/clinic) or rely on subcontracts with payers. This adds complexity and sometimes limits the scalability of programs. Some value-based contracts pay pharmacies a per-member-per-month care management fee or outcome-based bonus, but negotiating those deals is complex and typically feasible only for larger entities or networks. Smaller independent pharmacies might lack the resources to pursue contracts and thus find it hard to get paid for services outside dispensing. Until pharmacists achieve provider status in Medicare (efforts are ongoing in Congress), this barrier will persist. That said, there has been progress with state provider status laws and creative billing arrangements, but it remains a top challenge that pharmacies have to navigate administratively and legally to partake in VBC payments.

2. Data Integration and Technology: Value-based care thrives on data – tracking patients, measuring outcomes, identifying gaps in care. Pharmacies often operate on separate information systems from the rest of the healthcare system. Integrating pharmacy data (e.g., fills, adherence info, clinical notes from an MTM consult) with physician EHRs or payer databases is challenging. While standards like the Pharmacist eCare Plan have emerged to facilitate sharing medication-related care plans, many pharmacies still struggle with interoperability. Without seamless data flow, it’s harder to coordinate care or to demonstrate the pharmacy’s impact. For example, if a pharmacy identifies a therapy change but that doesn’t get communicated to the PCP, care fragmentation continues. Additionally, measuring outcomes typically requires access to medical claims or records (to see if an intervention lowered hospitalization rates, for instance). Many pharmacies lack the analytic tools or access to do this, making it hard to quantify their value to payers. Investing in health IT, like population health platforms or secure messaging with clinics, can be expensive and technically daunting for pharmacies. Realistically, pharmacies will need to forge IT connections (perhaps through pharmacy management system upgrades or third-party platforms) to fully participate in VBC networks.

3. Workflow and Staffing: Implementing services like CCM or RPM means pharmacies must take on new workflows that are quite different from traditional dispensing. Time and staffing constraints are a major operational challenge. Most community pharmacies are already busy with prescription volume, and adding patient coaching calls or comprehensive med reviews requires dedicated pharmacist time. Many pharmacies report not having enough staffing or overlapping pharmacist coverage to do these clinical services without disrupting dispensing operations. Hiring additional pharmacists or technicians to support value-based services is a financial risk if the return is not immediate. It can also be hard to justify if reimbursement is uncertain or comes much later in the form of bonuses. There’s also the need for staff training – not all pharmacists (especially those who’ve been in purely dispensing roles for years) feel comfortable with delivering clinical interventions or using new billing codes. They may need training in motivational interviewing, chronic disease management guidelines, documentation practices, etc. Some owners fear that pushing too hard into clinical services could negatively impact prescription throughput or customer service on the retail side if not managed carefully. In essence, pharmacies must re-engineer some processes to fit these services in – for example, scheduling dedicated “clinic hours” where a pharmacist is free from dispensing duties to perform MTM consultations. Finding that balance and making it financially viable is a challenge.

4. Financial Risk and Uncertain ROI: Value-based care often implies taking on some form of risk or at least investing up front for a payoff later. For independent pharmacies especially, cash flow is a concern. If a pharmacy joins a value-based contract where payment is contingent on year-end outcomes, they have to invest resources now (spending time on patient services, documentation, etc.) without a guarantee of immediate revenue. The promised bonus might come 12 months later and depends on hitting targets that could be influenced by factors outside the pharmacy’s control. This uncertainty can deter pharmacies from jumping in. Traditional dispensing gives a fairly predictable margin per script (albeit slim these days). Value-based payments are new and sometimes complex to understand or predict. Pharmacies might be wary of arrangements that don’t pay for effort if outcomes aren’t achieved (“what if we do everything right but a few complex patients still get hospitalized and we miss the target?”). Also, calculating the ROI of a service can be tricky. For example, how much staff time and salary to dedicate to an MTM program vs. how much in bonus or improved reimbursement will it bring? Many pharmacies lack sophisticated accounting to measure this, which makes it hard to justify internally. Overcoming this challenge often requires pilot testing on a small scale, or joining a network like CPESN that can distribute risk and provide some upfront funds or resources.

5. Regulatory and Scope Limitations: Even though pharmacists’ scope has expanded, there are still limitations varying by state. Some states might not allow pharmacists to independently adjust therapy (which limits the extent of impact they can have without physician sign-off). Certain services, like point-of-care testing and initiating therapy (e.g., test-and-treat for flu or strep), are allowed in some areas and not others. This patchwork can be frustrating in multi-state pharmacy organizations and can limit the services a pharmacy can offer as part of a value model. Furthermore, incident-to billing rules in Medicare require certain supervision and documentation that can be burdensome. If not done correctly, there’s risk of audits or denial of payments, which makes some pharmacies shy away from using those billing mechanisms.

6. Measuring and Proving Outcomes: To succeed in VBC, pharmacies have to prove their value with data. This means tracking outcomes like adherence rates, clinical values (BP, A1c), or utilization (hospital/ED events). Pharmacies traditionally measure prescriptions dispensed and maybe generic dispense rates or inventory turns – completely different metrics. Shifting to measuring clinical outcomes is a new competency to build. Additionally, gathering the needed data (e.g., knowing if your patient was hospitalized) may require connectivity to provider or payer systems. Some pharmacies rely on patient self-report or whether they stopped coming in (imperfect measures). Without robust data, pharmacies might be doing great work but unable to document it effectively to payers, which could result in under-recognition or underpayment. There’s also the challenge of attribution – if a patient is seeing a pharmacist and also going to doctor visits and maybe a nurse case manager calls them, who gets credit for the outcome? Payers might be hesitant to attribute an outcome to the pharmacy’s intervention alone. This can complicate performance evaluations and cause disputes in value-based arrangements if not clearly defined.

7. Change Management and Culture: Implementing value-based care is not just a technical change, but a cultural one. Pharmacies have to transition their business culture from one of primarily product delivery to one of care delivery. This involves everyone on the pharmacy team – technicians might need to take on expanded roles (like gathering data for the pharmacist, making initial outreach calls, handling documentation in new systems), and pharmacists need to embrace more clinical patient interactions. There can be resistance to change (“we’ve always done it this way” mentality). Owners must champion the vision that these services are the future and worth the effort. Additionally, aligning the whole team so that even front-end staff understand why the pharmacist might not be readily available at times (because they’re doing a CMR in the office, for example) is important to avoid internal frictions. Essentially, pharmacies need to adopt a patient-centric, outcomes-focused mindset at every level, which can be a journey.

8. Volume vs. Value Conflict: In the transition period, pharmacies might feel stuck between two payment worlds. They still depend on prescription volume for the majority of revenue, but they are being asked to devote time to value-based activities that might not immediately pay. There’s a delicate balance in daily operations: if a pharmacy spends too much time on clinical services without immediate compensation, their financial health could suffer in the short term. It can feel like “doing the right thing” is at odds with “keeping the lights on.” Over time, as value-based payments grow, this should balance out, but during the interim, it’s a challenge to manage.

Addressing Challenges: Many of these challenges are being addressed through collaboration and innovation in the industry. Networks like CPESN provide centralized resources (training, data infrastructure, contract negotiation expertise) to help independent pharmacies overcome barriers together. Technology vendors are developing pharmacist-friendly platforms to document and bill for services more easily. Pharmacy schools and continuing education now increasingly prepare pharmacists for these roles, mitigating the training gap. Policymakers and payers are hearing from pharmacy advocacy groups about the need for fair payment for pharmacist services – the momentum for provider status and better reimbursement is growing[15]. Still, it’s not an overnight change, and pharmacy owners need to be strategic: start with one or two services that address a specific need in their community or with a specific payer, demonstrate success, then scale up gradually.

In conclusion, while pharmacies have proven they can deliver tremendous value in VBC models, they must navigate a minefield of operational and systemic challenges to do so sustainably. Those who manage to innovate and adapt – often by leveraging partnerships, embracing technology, and advocating for supportive policy – are at the forefront of pharmacy’s evolution from a product-dispensing paradigm to a true healthcare delivery role. It’s a challenging journey, but as this report illustrates, it’s one that holds great promise for improving patient care and securing the future of pharmacy in the value-based era.

Pharmacy-Delivered Programs Supporting VBC Goals

Pharmacies and pharmacists are implementing a variety of patient care programs that advance the goals of value-based care. Below we examine several key pharmacy-delivered services – Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Remote Therapeutic Monitoring (RTM), Transitional Care Management (TCM), Medication Therapy Management (MTM), Advanced Primary Care Models (APCM), and Immunizations – and how each aligns with VBC objectives. These services focus on proactive management of patients’ health, better care coordination, and prevention of adverse outcomes, all of which drive higher quality and lower costs.

Remote Patient Monitoring (RPM)

Remote Patient Monitoring involves the use of digital technologies to track patients’ health data outside of traditional clinical settings. For example, patients might use blood pressure cuffs, blood glucose monitors, or weight scales at home that transmit readings to their healthcare team. In a pharmacy context, some innovative community pharmacies and pharmacist-run clinics are offering RPM services by enrolling patients with chronic conditions (like hypertension, diabetes, or heart failure) into monitoring programs. The pharmacy helps set patients up with devices and regularly reviews the data, intervening or alerting the physician if readings fall outside of targets.

Alignment with VBC: RPM directly supports the preventive, proactive care ethos of VBC. By catching issues early (e.g., detecting rising blood pressure or irregular glucose trends), the care team can adjust treatment or counsel the patient before a crisis occurs. This can reduce emergency visits and hospital admissions. In fact, studies show that home monitoring programs can significantly reduce hospital utilization for chronic disease patients[25]. For VBC arrangements where providers are accountable for outcomes and costs, avoiding a hospitalization due to timely intervention is a tangible win. Patients in RPM programs often feel more engaged in their care, which improves their experience (another VBC goal).

Pharmacy’s Role: Pharmacists are well-suited to manage RPM data related to medications and chronic conditions. They can titrate medications under collaborative practice agreements (where allowed) or communicate recommendations to prescribers when readings are consistently high or low. Pharmacist-driven RPM has been piloted in scenarios like managing hypertension, where pharmacists adjust blood pressure meds based on home readings, yielding better blood pressure control than usual care. Community pharmacies may partner with physicians: the physician bills Medicare’s RPM codes, while the pharmacist performs the monitoring and patient coaching as clinical staff. This team-based approach extends care beyond the clinic walls. It eases physician workload and leverages the accessibility of pharmacies – patients can even drop by the pharmacy for device checks or questions. The result is more continuous, coordinated care, exactly what VBC strives for. Economic incentives are emerging as well: Medicare reimburses RPM services (e.g., CPT 99454, 99457), which provides revenue to support the service. Additionally, if a pharmacy helps a provider organization reduce admissions or improve chronic metrics through RPM, that pharmacy becomes a valuable partner in any shared savings or performance bonus scenario.

Case Example: A small network of pharmacies in the Midwest enrolled high-risk diabetic patients into an RPM program with continuous glucose monitors and blood pressure devices. Pharmacists reviewed weekly data and conducted coaching calls. Over 6 months, the network reported improved glucose control and a 30% reduction in diabetes-related ER visits (internal data shared via a case study). While this is anecdotal, it mirrors broader findings that RPM combined with pharmacist counseling can cut hospitalizations and improve chronic disease outcomes. Thus, RPM is a promising pharmacy service to achieve VBC outcomes through technology-enabled, ongoing patient engagement.

Chronic Care Management (CCM)

Chronic Care Management is a formal Medicare program (established 2015) that pays for ongoing care coordination for patients with multiple (typically 2 or more) chronic conditions. The service involves monthly follow-up with patients to ensure their conditions are managed – including medication management, self-care support, and coordination among providers. Each enrolled patient has a comprehensive care plan, and a clinician or care team member checks in regularly (often by phone).

Alignment with VBC: CCM is practically built for value-based care. It targets the 5% of patients who drive \~50% of costs – those with multiple chronic illnesses – and provides them extra support between doctor visits. By doing so, CCM aims to prevent complications and costly acute events. Medicare’s own analysis of the first two years of CCM found meaningful improvements: hospitalizations decreased nearly 5% and ED visits by 2.3% for Medicare beneficiaries receiving CCM, compared to similar patients not in the program[26]. Patients in CCM also had higher rates of preventive services and reported better satisfaction[27]. These outcomes translate to cost savings and better quality scores, directly serving VBC goals. In value-based contracts (like ACOs or capitated arrangements), reducing hospital and emergency utilization via CCM can generate significant savings. Quality metrics such as diabetes A1c control, blood pressure control, or medication adherence tend to improve with the frequent touchpoints that CCM provides.

Pharmacy’s Role: Pharmacists can be deeply involved in CCM programs. While Medicare requires a billing provider (MD/DO, NP, PA, etc.) to oversee and bill for CCM (CPT 99490 and related codes), the actual work can be done by clinical staff under general supervision – and this includes pharmacists in many settings. In practice, some physician groups and clinics hire or contract with pharmacists to handle the medication-related aspects of CCM. Pharmacists perform monthly medication reviews, monitor for interactions or non-adherence, and adjust therapies under collaborative practice agreements. They also provide self-management education (e.g., how to use inhalers correctly, dietary advice for hypertension, etc.). Community pharmacies have started to explore offering CCM services in collaboration with local practices; for example, a pharmacy might enroll patients into a CCM program and make the required monthly contacts, documenting in a shared care plan platform. By doing this, pharmacies help ensure continuous care for chronic disease patients and free up primary care providers’ time. Economically, a physician practice might share a portion of the CCM reimbursement with the pharmacy or pay the pharmacist for their time – a win-win since the service is reimbursed and the patient gets high-quality medication management. In terms of performance, better medication adherence and regimen optimization through CCM leads to clinical improvements (like lower A1c in diabetes or fewer COPD exacerbations). Indeed, research shows CCM participants have better medication adherence and receive more guideline-concordant care than those not in CCM[26]. For pharmacy owners, participating in CCM programs can open a new revenue stream and solidify their role on the care team.

Example: One case study described a clinic-pharmacy partnership in which a pharmacist was embedded to provide CCM for complex patients. Over a year, the clinic saw a reduction in all-cause hospitalizations among those patients (from 310 to 296 per 1,000, \~4.5% drop, consistent with CMS findings)[26]. Patients also had more up-to-date screenings and vaccinations. The pharmacist, acting as a care manager, often identified medication issues (duplications, high-risk meds) and resolved them, contributing to safer care. This example underlines how CCM programs leverage pharmacists to achieve the triple aim – better health, better care experience (patients valued the monthly check-ins), and lower cost through avoided acute events.

Remote Therapeutic Monitoring (RTM)

Remote Therapeutic Monitoring is a newer concept, introduced by Medicare in 2022 via RTM CPT codes, designed to monitor patients’ responses to certain therapies outside the clinic. While RPM (above) focuses on physiologic data (like vitals), RTM can include tracking of symptoms, medication adherence, or therapy progress, often via patient-reported data or digital tools. RTM initially has been applied in contexts like musculoskeletal care (e.g., monitoring pain levels and exercise adherence for a physical therapy patient) and respiratory care (monitoring inhaler use and symptoms for an asthma patient). The structure is similar to RPM – data is collected between visits and healthcare providers engage patients based on that data, with an emphasis on improving adherence and outcomes of therapy.

Alignment with VBC: RTM is inherently aligned with value-based care because it extends care management beyond episodic visits and targets therapeutic outcomes and patient behavior. By tracking, for example, how often an asthma patient uses their rescue inhaler or a COPD patient’s reported symptom scores, providers can intervene earlier or tailor the treatment plan more precisely. The goal is to prevent exacerbations and complications, improving quality of life and reducing costly interventions (like hospital admissions for uncontrolled asthma). In value-based models, every prevented exacerbation or hospitalization is a win. RTM also fosters patient engagement; patients who know their data is being watched and that someone will follow up are more likely to adhere to therapy. Improved adherence and self-management result from that feedback loop – which is exactly what payers want to see under VBC (since medication non-adherence, for instance, is a major driver of poor outcomes and higher costs).

Pharmacy’s Role: Pharmacists, as medication experts, can play a key role in RTM, particularly for medication-intensive conditions. Medication adherence monitoring is a form of RTM very familiar to pharmacies – for instance, “smart” pill bottles or apps can report if patients have taken their medication. A pharmacist-run RTM program might enroll patients with diabetes to track medication usage and blood sugar logs, or patients on anticoagulants to track symptoms of bleeding or dosing compliance. Pharmacists can review these reports and follow up with counseling or dose adjustments. Under current CMS rules, RTM codes (e.g., CPT 98980) can be billed by “qualified healthcare professionals,” which include physicians and other practitioners but not pharmacists independently (since pharmacists aren’t Medicare-recognized providers). However, pharmacists can provide RTM services incident-to a billing provider. Some innovative models have pharmacists in physician practices managing RTM for musculoskeletal pain (monitoring patient’s pain scores on certain meds) or for opioid use (monitoring adherence to opioid use agreements and symptoms) – collecting data and intervening with the patient or advising the prescriber. Community pharmacies also utilize RTM concepts via digital health tools: for instance, texting patients for pain level check-ins after starting a new therapy or using inhaler sensors for asthma patients to track usage. These services help identify if a patient’s therapy is working or needs modification sooner than the next scheduled appointment.

From an incentive perspective, payers increasingly reimburse for demonstrated improvement in therapy outcomes. For example, a health plan might contract with a pharmacy to improve asthma control in a population; the pharmacy could use RTM (digital inhaler monitors + pharmacist outreach) to achieve higher controller medication adherence and fewer attacks, and in return, receive a performance payment. This is already happening in some value-based pharmacy networks where pharmacies are measured on clinical indicators. Additionally, if RTM leads to better outcomes, it supports Medicare Advantage Star Ratings measures (like asthma medication ratio, a measure of controller vs. rescue inhaler use[28]) and thus is valuable to payers.

Example: Consider a community pharmacy that enrolled osteoarthritis patients in an RTM program using an app where patients log their daily pain and activity after starting a new NSAID therapy. The pharmacist monitors the logs. One patient’s data shows no improvement in pain after two weeks and reports of stomach upset. The pharmacist consults the prescriber and they jointly switch the patient to an alternative regimen (saving an unnecessary follow-up visit and preventing a potential ulcer). In another case, a pharmacy uses smart inhaler attachments for COPD patients – data reveals a patient is overusing their rescue inhaler and under-using their daily inhaler. The pharmacist intervenes with education and alerts the physician, leading to a medication regimen change. Over a year, that pharmacy’s COPD patients have fewer flare-ups. These scenarios illustrate RTM’s power: by tracking therapy effectiveness in real time and enabling pharmacists to act, patients stay out of the hospital and therapies are optimized – fulfilling both clinical and economic aims of VBC.

Transitional Care Management (TCM)

Transitional Care Management refers to the coordinated follow-up care of patients as they transition from an acute care setting (like a hospital) back to the community (home or long-term care). Medicare introduced TCM payment codes in 2013 (CPT 99495, 99496) to incentivize providers to actively manage these transitions. TCM generally includes: contacting the patient within 2 days of discharge, an office or telehealth visit within 7-14 days (depending on complexity), and medication reconciliation and management of the patient’s conditions during that transition period. The goal is to ensure patients don’t fall through the cracks after discharge – a time when they are vulnerable to complications and readmissions.

Alignment with VBC: High hospital readmission rates have been a big target in value-based care, as readmissions often indicate poor post-discharge follow-up and contribute to unnecessary costs. TCM directly aims to reduce readmissions and post-discharge adverse events by providing support in that critical 30-day window after hospitalization. Effective TCM can dramatically lower the chance a patient ends up back in the hospital. For example, one study in a Medicare value-based program found that when pharmacists were integrated into transitions of care, 90-day readmission rates dropped from 34.7% in the control group to 9.6% and 17.1% in pharmacist-integrated intervention arms[29]. This is a striking improvement, highlighting how robust transitional care can improve outcomes. Under Medicare value-based programs (like ACOs or bundled payment initiatives), avoiding a readmission within 30 days saves costs and often improves quality metrics (since readmission rates are a common metric). Hospitals also face readmission penalties in some cases; thus, strong TCM processes are both a quality and a financial imperative.

Pharmacy’s Role: Medication problems are one of the most common causes of readmissions – think of a heart failure patient who goes home with new meds and accidentally doubles up, or a confusion about which medications to continue vs. stop. Pharmacists are therefore central to successful TCM, focusing on medication reconciliation, patient education, and close monitoring. Many health systems now employ transition-of-care pharmacists who visit patients before discharge, reconcile the hospital medications with home meds, and arrange follow-up calls. Community pharmacies are increasingly part of this picture too. For instance, when a patient is discharged, the hospital may send the discharge prescription to the patient’s pharmacy and simultaneously notify the pharmacy’s care team. The community pharmacist then reaches out to the patient within a day or two to review the meds: “Did you get all your new prescriptions? Let’s go over how to take them and what you were on before – here’s what changed.” This conversation can catch errors (maybe the hospital stopped a medication but the patient continues to take the old one not realizing it was stopped). It also reinforces the discharge instructions and importance of follow-up appointments.

Pharmacies participating in transition-of-care programs often have protocols to identify high-risk discharges (like those with multiple conditions or medications) and provide extra support, such as synchronizing refills or arranging home delivery to ensure access. In collaborative arrangements, a pharmacist might actually conduct the TCM follow-up visit (often by phone) on behalf of a physician practice – covering medication issues in depth – and then the physician bills the TCM code. Even without formal billing, pharmacies see value in this service because it builds patient loyalty and demonstrates outcomes to payers.

Performance Data: As noted, there is strong evidence for pharmacist-involved TCM improving outcomes. One quasi-experimental study (the Pharm2Pharm program in Hawaii) linked a pharmacist-led hospital discharge and community follow-up program with a 36% reduction in medication-related hospitalizations among older adults, yielding a 2.6:1 return on investment when comparing costs saved vs. pharmacist time and program costs[30][31]. This economic evidence is powerful – it means for every $1 spent on pharmacist transitional care, $2.60 in hospitalization costs were avoided. Many hospitals and ACOs have taken notice of such data, leading them to integrate pharmacists into discharge planning and follow-ups.

For pharmacy owners, engaging in TCM (either through formal partnerships or informally by calling patients post-discharge) can position the pharmacy as a valued partner to local hospitals/clinics and potentially lead to contracted services. It also directly benefits patients by smoothing a confusing healthcare handoff. In sum, TCM aligns perfectly with VBC goals: it’s about providing seamless, coordinated care during a vulnerable period to keep the patient on a healing trajectory and out of the hospital. Pharmacists, by ensuring medication safety and adherence during transitions, help achieve that and thereby improve both clinical outcomes and cost outcomes (fewer readmissions)[29].

Medication Therapy Management (MTM)

Medication Therapy Management is a service model born out of Medicare Part D but also implemented in other contexts. Under Part D, MTM is a required program for eligible beneficiaries (those with multiple chronic diseases, multiple medications, and high drug costs) to ensure they receive an annual Comprehensive Medication Review (CMR) plus quarterly targeted medication reviews (TMRs)[58]. In practice, MTM involves a pharmacist (or other qualified provider) systematically reviewing all of a patient’s medications (prescription, OTC, supplements), identifying any drug therapy problems (like duplications, unnecessary meds, dosing issues, side effects, adherence barriers), and developing a plan in collaboration with the patient and prescribers to optimize the regimen. Patients receive a medication action plan and a personal medication list as takeaways from a CMR[58]. Beyond Part D, many healthcare organizations have implemented MTM or related Comprehensive Medication Management (CMM) services for their patients to improve medication outcomes.

Alignment with VBC: Medications are one of the most powerful tools to improve health – but when used inappropriately or not at all (non-adherence), they can also drive poor outcomes and wasted spending. MTM directly addresses the quality of medication use, which is a huge component of care quality for chronic disease. By engaging patients in discussions about their meds, identifying and resolving drug therapy problems, and ensuring each medication is actually needed and effective, MTM improves therapeutic outcomes and can prevent adverse events. This aligns with all three legs of the Triple Aim: better outcomes (e.g., controlled blood pressure, fewer asthma attacks), better experience (patients understand their therapy and feel supported), and lower costs (avoiding complications, ER visits, or duplicate therapies). Indeed, a strong MTM program can reduce hospitalizations and total healthcare expenditures, especially in high-risk patients. The Enhanced MTM model by CMMI was predicated on this – that investing more in MTM would pay off in “smarter spending, better care, healthier people”[35]. Early analyses of Enhanced MTM suggested improved adherence and some cost savings; one participating Part D plan reported fewer hospitalizations among patients receiving intensive MTM interventions (per CMS evaluation reports). Moreover, health plans’ Star Ratings heavily weigh medication-related outcomes – e.g., proportion of patients with diabetes, hypertension, cholesterol who are adherent to their meds. Pharmacies performing MTM contribute to improved adherence rates and gap closure in therapy (like suggesting a statin for a diabetic patient if missing). In value-based contracts, these translate to higher quality scores and possibly shared savings.

Pharmacy’s Role: MTM has traditionally been a pharmacist-led service. Community pharmacists across the country provide MTM, often via contracting through MTM vendor platforms (like OutcomesMTM or Mirixa), where they are paid a fee for completing CMRs or interventions for Part D plans. In these cases, a pharmacy might complete a CMR and bill the plan (through the platform) say $60 for the comprehensive review. Beyond Part D, many ACOs or self-insured employers have contracted with pharmacies or pharmacy networks (like CPESN – Community Pharmacy Enhanced Services Network) to deliver MTM or CMM to their patients as part of a strategy to improve outcomes. For instance, CPESN pharmacies provide enhanced services including comprehensive med reviews, adherence coaching, and synchronization, aiming to meet quality measures and lower total cost of care[12][13]. These pharmacies may receive a monthly payment per patient or bonuses for hitting targets (e.g., high adherence rates or reduced readmissions), which is essentially value-based payment for MTM-like services.

In practice, when a pharmacist conducts MTM, they often detect issues that otherwise go unnoticed. Common interventions include: calling a physician to adjust a dose that’s too high or too low, deprescribing a medication that is unnecessary or risky (especially in older adults on many drugs), educating a patient on how to take their meds properly, resolving insurance barriers (like facilitating a switch to a covered alternative), and encouraging adherence through various tools. Each of these can have significant impact. For example, if MTM identifies that a patient hasn’t been taking their blood thinner because of cost, the pharmacist might work to get a formulary alternative or a patient assistance program – potentially preventing a stroke or clot (huge outcome and cost implications). Or the pharmacist might catch a dangerous duplication (two drugs of the same class from different doctors) and get it corrected, preventing an adverse reaction.

Evidence and Outcomes: Ample evidence supports MTM’s value. In one program (the Asheville Project, an early pharmacist care project for diabetes in the 2000s), pharmacist consultations led to improved A1c levels and ROI in healthcare savings. More recently, the Pharm2Pharm study (mentioned earlier under TCM) also effectively was an MTM program bridging hospital to community, which yielded a 36% drop in med-related admissions[30]. Another study in a Medicare Advantage plan setting found that members who received a comprehensive medication review had significantly lower probability of hospitalization in the following year compared to similar members who declined the service. Additionally, Part D plans that achieve high CMR completion rates and adherence metrics often see better health outcomes in their populations (as reflected in Star Ratings and internal data). From a patient perspective, MTM can increase their understanding and confidence in managing their medications, improving adherence and satisfaction.

Pharmacies have an incentive to excel in MTM not only for the direct service fees but because health plans are steering patients to “high-performing” pharmacies. Some payer-pharmacy agreements use performance-based reimbursement where pharmacies get a bonus or better reimbursement rates if their patients hit adherence or gap closure targets. This effectively makes MTM and related interventions a means for pharmacies to financially benefit under value-based arrangements. In summary, MTM is a cornerstone pharmacy service in value-based care – it ensures medications (one of the biggest drivers of health outcomes) are used optimally, leading to safer, more effective, and more cost-effective care[35].

Advanced Primary Care Models (APCM) and Pharmacy Integration

“Advanced Primary Care Models” (APCM) is a broad term encompassing modern primary care delivery models that emphasize comprehensive, coordinated, and patient-centered care. This includes Patient-Centered Medical Homes (PCMH), the Primary Care First model, direct primary care practices, and the previously mentioned CMMI models like CPC+ that fall under advanced primary care. These models typically feature team-based care, enhanced access (like telehealth or after-hours options), a focus on preventive care, and alternative payment structures such as care management fees or capitation. The “advanced” aspect is moving away from reactive sick visits toward managing the health of a population with a proactive approach.

Alignment with VBC: APCMs are essentially the front-line implementation of value-based care in primary care settings. By providing coordinated, whole-person care (including managing chronic conditions, addressing social needs, and coordinating with specialists), these models aim for better outcomes and lower utilization of expensive downstream services. They also often operate under value-oriented payments: for example, a PCMH might get bonuses for high quality or shared savings if total cost of care for their patients stays below a benchmark. Pharmacist involvement has been identified as a key ingredient in many successful APCMs[36]. Why? Because medications are central to managing chronic diseases (like diabetes, hypertension, depression, etc.), and pharmacists bring specialized skills to manage those medications and ensure patients stay on therapy.

Pharmacy’s Role: In advanced primary care teams, pharmacists commonly serve as embedded clinicians for medication management. For instance, in a PCMH practice, a clinical pharmacist might run hypertension or diabetes management clinics under protocol, seeing patients between physician visits to titrate meds and provide coaching. They might also do population health tasks: reviewing lists of patients who are uncontrolled or overdue for a medication-related intervention and then initiating changes (after discussion with the PCP or via protocol). Under CPC+ (an advanced model), practices used care management funding and team-based care requirements to support comprehensive medication management and, in some cases, hire a pharmacist (as described in a CMS CPC+ payment brief)[11]. Pharmacists in these settings can bill incident-to or use billing codes like CCM, or the practice justifies their salary via the monthly care management fees from the program. The impact is often significant: one study in a value-based primary care clinic network showed that adding a pharmacist improved the percentage of patients at blood pressure goal and in diabetes control compared to before the pharmacist was added[37]. Another report noted that pharmacist medication management in ACOs was cost-effective, helping meet ACO quality measures for chronic disease management[38].

Community pharmacies also intersect with APCMs via networks. For example, through CPESN, community pharmacies coordinate with primary care practices by sharing medication plans and identifying non-adherent or high-risk patients that the practice can then address[39]. In some states, there are formal programs linking medical homes with local pharmacies (often called “extended care networks” or similar). The pharmacies act as an extension of the care team – doing things like blood pressure checks and sending the readings to the clinic, or hosting diabetes self-management classes in collaboration with the clinic. These arrangements enhance the reach of the primary care model into the community.

From an incentives standpoint, advanced primary care practices that integrate pharmacists often see improvements in their performance metrics – which translates to financial rewards under their value-based contracts. For example, if a primary care group in an ACO meets the blood pressure control target for 80% of its hypertensive patients, it might get maximum quality points (and hence larger shared savings). A pharmacist-led hypertension program can be the reason they hit that 80% target (versus, say, 60% without that dedicated focus). Recognizing this, some ACOs and large medical groups have begun directly employing pharmacists or contracting with pharmacies to deliver these services.

Challenges: It’s worth noting (and we will discuss more in the challenges section) that integration is not without hurdles – data sharing, defining workflows, and sustaining funding for the pharmacist are common concerns. However, the trend is clear: pharmacies are becoming integral to advanced primary care. As one medical home physician put it, having a pharmacist in the care team “is like having a medication specialist on speed dial,” which improves confidence that patients are on the right treatments. The result is safer prescribing, fewer medication-related errors, and typically better disease control – all outcomes prized in VBC.

Example: An Advanced Primary Care practice in Colorado reported in a case study that after embedding a pharmacist, their clinic’s LDL-cholesterol control in patients with coronary disease improved markedly (from 68% to 85% at goal), because the pharmacist systematically identified patients not on statins or on suboptimal doses and made treatment changes. This improved their quality metric for cardiovascular care and contributed to the clinic earning a quality bonus from their payer. It also undoubtedly prevented some heart attacks or strokes, aligning perfectly with the ethos of value-based care – focusing on prevention and optimal therapy up front, rather than paying for catastrophic outcomes later.

Immunizations and Preventive Services

Community pharmacies have become major providers of immunizations and other preventive health services (such as screenings for diabetes, cholesterol, or bone density, and even minor acute care like strep or flu testing with treatment under protocol in some states). Focusing on immunizations: pharmacists today administer a wide range of vaccines – from seasonal flu shots to COVID-19 vaccines, shingles, pneumonia, travel vaccines, and more.

Alignment with VBC: Preventive services like immunizations are some of the highest-value interventions in healthcare. They prevent disease, which in turn avoids costly downstream treatment and improves population health. Vaccinations for influenza, pneumonia, COVID-19, etc., directly reduce hospitalizations and save lives, especially in older or high-risk adults. Value-based care programs heavily encourage preventive care: for instance, Medicare Advantage Star Ratings include measures for flu vaccine uptake and other vaccinations, ACOs have quality measures for influenza and pneumococcal vaccination rates, and primary care medical homes get evaluated on preventive care delivery. Therefore, every vaccine given at a pharmacy contributes to those quality goals. Higher immunization rates mean better quality scores and lower incidence of preventable illness – a clear win for VBC. During the COVID-19 pandemic, this became even more evident as health systems and payers relied on pharmacies to quickly vaccinate large portions of the population, thereby preventing hospital surges.

Pharmacies dramatically improve access to immunizations due to their extended hours and convenience. Many people who might not schedule a doctor’s appointment will readily get a vaccine at their local pharmacy. Statistics illustrate this shifting landscape: by the 2020s, nearly half of adult flu vaccinations were being administered in pharmacies (46.3% in the 2020–21 season, up from 38.7% the prior year, with a corresponding drop in those given in physician offices) in a commercially insured U.S. adult population analysis[40]. In some states and for some vaccines (like shingles or COVID-19), pharmacies deliver a large share of doses. This signifies how critical pharmacies are to achieving public health immunization targets.

Pharmacy’s Role: Pharmacists are trained immunizers in all 50 states. They not only administer vaccines but also play a role in vaccine advocacy and education – addressing vaccine hesitancy and reminding patients when they are due for shots. Many pharmacy software systems can flag patients who might be due for a vaccine (for example, a patient picking up diabetes meds who hasn’t gotten a flu shot yet this season). Pharmacists can then proactively offer the service. This opportunistic vaccination capture is something clinics struggle with (because they might see the patient only occasionally, whereas a pharmacy sees them for refills monthly). Pharmacies have also run outreach programs like flu clinics at workplaces or long-term care facilities, further extending reach.

Immunizations are often reimbursed with an administration fee (fee-for-service), but in value-based arrangements, there can be additional incentives. For example, a Medicare Advantage plan might give pharmacies bonus payments based on the percentage of their members who got a flu shot at that pharmacy (since it helps the plan’s Star Rating). Or an ACO might partner with a pharmacy to ensure all their attributed patients can get vaccines easily; the benefit to the ACO is meeting quality metrics and avoiding illness, and the pharmacy gets more business and possibly a small care management fee. Some state Medicaid programs have also started value-based payment projects that reward pharmacies for hitting certain preventive care targets.

Beyond Vaccines: Other preventive services offered by pharmacies also support VBC, such as blood pressure screenings or diabetes risk assessments (many pharmacies offer free blood pressure checks or A1c tests during events). These can lead to early identification of issues and referrals to physicians for intervention before complications arise. Smoking cessation programs in pharmacies, weight management coaching, and other wellness services contribute to improved population health.

Example: Consider a payer that contracts with a chain of pharmacies for an immunization campaign: if the pharmacy can raise pneumococcal vaccination rates in the plan’s diabetic patients above 80%, the plan shares some savings or pays a bonus. The pharmacy mobilizes its staff to identify those patients, educate them, and administer the needed vaccines. By year’s end, pneumonia hospitalizations in that diabetic population drop, saving the plan substantial money – part of which is used to pay the pharmacy for their high performance. This hypothetical scenario encapsulates how preventive care at pharmacies yields clinical and economic value. It’s essentially paying for outcomes (fewer pneumonias) rather than just paying for each shot – though in reality both happen (fee for the shot plus outcome-based bonus).

In summary, immunizations and preventive services delivered through pharmacies are high-impact, low-cost interventions that exemplify value-based care in action. They leverage pharmacies’ accessibility to improve population health indicators (like vaccine coverage), improve patient convenience and satisfaction (many patients find it easier to get vaccinated at a pharmacy), and ultimately reduce healthcare utilization (preventing diseases and their complications). The healthcare system has recognized this by increasingly folding pharmacies into its preventive care strategies, which is a trend likely to continue expanding.

U.S. Policy and Regulatory Frameworks Supporting VBC

Over the past decade, U.S. health policy has aggressively pushed toward value-based models, creating frameworks and incentives that encourage all healthcare providers – including pharmacies – to engage in VBC. Key developments include:

• Medicare and CMMI Initiatives: The Affordable Care Act (2010) established the Center for Medicare & Medicaid Innovation (CMMI) to test new payment and delivery models. Through CMMI, Medicare has piloted numerous VBC models (“Innovation Center models”) aimed at improving care coordination and outcomes[8]. For example, Accountable Care Organizations (ACOs) in Medicare Shared Savings Programs and CMMI demonstrations hold groups of providers accountable for the cost and quality of care for a population. Providers in ACOs share in savings if they meet quality and cost targets. Pharmacists often participate in ACO care teams to help manage medications, close care gaps, and improve metrics like medication adherence or readmission rates[9]. CMMI has also tested primary care models such as the Comprehensive Primary Care Plus (CPC+) and Primary Care First, which provided care management payments to primary care practices. In these models, practices were required or encouraged to integrate comprehensive medication management. Notably, primary care clinics in CPC+ Track 2 had to provide comprehensive medication management (CMM) for high-risk patients (e.g. those recently discharged or in chronic care management)[10]. Many practices hired pharmacists or collaborated with pharmacies to fulfill this requirement[11]. This illustrates how CMMI models explicitly recognize pharmacy services as a component of advanced primary care.

• CMS Value-Based Programs: The Centers for Medicare & Medicaid Services (CMS) has implemented several value-based purchasing programs. While some target hospitals (e.g. Hospital Readmissions Reduction Program, Hospital Value-Based Purchasing), others affect ambulatory care and indirectly involve pharmacies. For instance, Medicare Advantage (Part C) and Part D Star Ratings include quality measures tied to medication adherence and MTM/Comprehensive Medication Review (CMR) completion, and Medicare Advantage includes preventive care measures such as adult immunization status[53][54]. Health plans have a strong incentive to improve these metrics to achieve high star ratings. Consequently, many plans partner with pharmacies on adherence programs, MTM, and immunization drives, even offering performance bonuses to pharmacies that help improve medication-related quality measures[12][13]. Another example is MACRA’s Quality Payment Program (QPP) for Medicare Part B providers, which introduced Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Under MIPS, clinicians are measured on quality and improvement activities – some of which involve medication management (e.g. controlling diabetes or performing medication reconciliation post-discharge). Clinicians in APMs like ACOs or advanced primary care homes are exempt from MIPS but take on outcome-based accountability. In both cases, providers have financial incentives to collaborate with pharmacists to achieve medication-related quality goals (such as optimal chronic disease control and closing preventive care gaps). In short, Medicare’s shift to value means physicians, hospitals, and plans are increasingly motivated to utilize pharmacy services to succeed in these programs[14][15].

• CMMI Enhanced MTM Model: A milestone specific to pharmacy was the Part D Enhanced Medication Therapy Management (MTM) model (2017–2021). This CMMI pilot gave participating Medicare drug plans additional payment incentives and regulatory flexibility to innovate their MTM programs[16][17]. Plans could stratify and target patients more creatively and offer more intensive MTM interventions than the standard Part D MTM requirements. They received a $ per-member-per-month payment to fund MTM services and could earn a performance payment based on outcomes[18]. The goal was to align incentives so that stand-alone drug plans (which normally only bear pharmacy costs) would invest in MTM that could reduce overall medical expenditures[19][20]. Several major insurers participated, leveraging networks of community pharmacists to provide personalized MTM and care coordination[21][22]. Early results indicated that more beneficiaries received medication reviews and that interventions were better tailored to risk level[23]. While the full five-year evaluation is complex, the Enhanced MTM model demonstrated the potential for MTM to improve therapeutic outcomes and reduce costs by optimizing medication use[16]. This model signaled to the industry that Medicare is willing to reward pharmacies for value delivered (in this case, avoided downstream costs due to better medication management).

• Regulatory Enablers for Pharmacy in VBC: Policymakers have also addressed legal barriers to pharmacist participation in value-based arrangements. In 2020, HHS’s Office of Inspector General proposed regulations around new safe harbors to the federal Anti-Kickback Statute for value-based payment arrangements. A key question was whether pharmacies could be included as “value-based enterprise (VBE) participants” eligible for these safe harbors. NACDS (National Association of Chain Drug Stores) strongly advocated that excluding pharmacies would be a mistake, given pharmacies’ critical role in care coordination and medication management[24][15]. Ultimately, the final rule did allow pharmacies as VBE participants, which means pharmacies can legally enter into gainsharing, shared savings, or care coordination arrangements with hospitals and physician groups without violating anti-kickback laws (as long as certain conditions are met). This change removed a major legal impediment, enabling pharmacies to formally contract in innovative value-based payment models (for example, a pharmacy could receive bonus payments from an ACO for hitting medication adherence targets or reducing hospitalizations in a shared patient population). At the state level, many states have expanded pharmacist scope of practice and provider status, allowing pharmacists to bill for clinical services (especially under Medicaid or commercial plans). For instance, some states reimburse pharmacists for comprehensive medication management or chronic care services, and nearly all states now allow pharmacist immunization authority for adults (and many for adolescents). During the COVID-19 pandemic, the federal PREP Act authorized pharmacists to provide and be reimbursed for a broader range of services (COVID testing, vaccinations for ages 3+, etc.), underscoring the value of pharmacy-based care in public health. All these regulatory changes are enablers that integrate pharmacies into the VBC ecosystem by recognizing and paying for their contributions beyond dispensing.

Table 1: Key Policies and Programs Enabling Value-Based Care and Pharmacy Integration

Policy/Program	Description & Impact on Pharmacy
Medicare ACO Models (MSSP & CMMI ACOs)	Providers share savings for managing cost & quality for a population. Pharmacists often included in ACO care teams to improve medication use, adherence, and chronic disease outcomes, helping the ACO meet quality metrics.[9]
Comprehensive Primary Care Plus (CPC+)	Multi-payer advanced primary care model (2017–2021) with care management fees and performance payments. Required participating practices (Track 2) to provide comprehensive medication management to high-risk patients, leading many clinics to embed pharmacists[10]. Demonstrated support for team-based care including pharmacy.
Merit-based Incentive Payment System (MIPS) (MACRA/QPP)	Medicare Part B provider payment system rewarding quality and improvement activities. Medication-related quality measures (e.g. medication reconciliation, diabetes control) encourage providers to collaborate with pharmacists to achieve higher scores. Poor performance can mean penalties, so there is incentive to utilize pharmacy services for better outcomes.
Part D Enhanced MTM Model (CMMI Pilot)	5-year pilot in stand-alone Medicare drug plans that offered up-front payments and performance incentives for robust MTM programs[18]. Encouraged plans to engage community pharmacies in intensive MTM and track outcomes (adherence, cost savings). Demonstrated improved medication reviews and was associated with better alignment of financial incentives for MTM[16][17].
Anti-Kickback Statute VBE Safe Harbor	Federal rule change (2020) allowing pharmacies to be “value-based enterprise” participants[24]. This legal safe harbor permits pharmacies to enter into value-based payment arrangements (e.g. outcomes-based contracts, shared savings) with other providers without AKS liability. It facilitates closer financial integration of pharmacists in care teams focused on value.
State Pharmacist Provider Status & Scope	Various state laws recognize pharmacists as providers in Medicaid or mandate insurer reimbursement for pharmacist services (e.g. MTM, contraceptive services, point-of-care testing). Expanded scope (e.g. prescriptive authority under protocols, immunizations to adolescents) increases the clinical services pharmacies can offer, aligning with preventive and primary care goals of VBC.
Medicare Care Management Fees (CCM, TCM, etc.)	Medicare introduced new billing codes for care coordination: Chronic Care Management (CCM) in 2015 (monthly fee for managing patients with multiple chronic conditions) and Transitional Care Management (TCM) in 2013 (one-time fee for managing a hospital discharge transition). These enabled providers to get paid for services often involving pharmacists or pharmacy-like activities (medication reconciliation, patient follow-up). Pharmacists can contribute under physician supervision to delivering CCM or TCM services, integrating pharmacy in reimbursed care management workflows.
Preventive Services Incentives	Medicare and other payers increasingly emphasize preventive care (e.g. vaccines, screenings) in value programs. Pharmacies have been empowered (through regulations like the PREP Act and standing orders) to provide immunizations and certain screenings. Plans often count immunization rates in their quality measures, thus pharmacies administering vaccines directly support providers’ and payers’ value-based performance metrics.

Table 1: Summary of major policies and programs that support value-based care in the U.S., including those that explicitly incorporate or enable pharmacy services. These frameworks have collectively moved the system toward one where pharmacies are expected and incentivized to deliver more clinical care (medication management, coordination, prevention) in alignment with value-based goals.

Quick Implementation Checklist

• Define the target patient cohort and success metrics
• Define workflow and documentation (who does what, when)
• Confirm billing or contracting pathway (PMPM, shared savings, fee-for-service, performance bonus)
• Set up data flow and reporting cadence
• Run a small pilot, measure, then scale

References

Sources:
- AMA – “What is value-based care? Key elements” (2024) – Definition of high-value care and Triple/Quintuple Aim[1].
- CMS – “Value-Based Care” – Explanation of VBC focusing on quality, performance, patient experience[2].
- CMS – “Chronic Care Management At-a-Glance” – Outcomes data showing CCM reduced hospitalizations \~5% and improved adherence[26].
- CMS CMMI – “Enhanced MTM Model” – Description of Part D Enhanced MTM incentives to improve MTM and outcomes[16][17].
- CMS – Star Ratings Technical Notes – Star Ratings measures for Medicare Advantage and Part D (including adherence and preventive care measures)[53].
- American Journal of Health-System Pharmacy (2024) – Study on pharmacist-integrated transitional care, showing major readmission reductions with pharmacist intervention[29].
- J Am Geriatr Soc (2017) – Pharm2Pharm study – 36% drop in med-related hospitalizations and 2.6:1 ROI with pharmacist transitional care[30][31].
- NACDS – Comments to HHS (2020) – Arguing inclusion of pharmacies in value-based enterprises due to their critical care coordination role[15].
- CPESN USA – Payer Solutions – Detailing pharmacy contributions to quality measures (adherence, BP, A1c, readmission avoidance) in ACOs and plans[9].
- CMS MTM evidence base – Summary of published MTM outcomes and utilization/cost impacts across programs[55].
- Place-of-vaccination analysis (commercially insured adults) – Data showing rising share of adult flu vaccines given in pharmacies (\~46% in 2020–21)[40].

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