What is the cost of a single point reduction in your Star Rating? For most health plans, the answer is millions. Take Humana, for instance. Humana’s loss from a single contract dropping from 4.5 to 3.5 stars in 2025 was estimated to be up to $2.8 billion in unmitigated financial impact. Across all plans, a 0.5-star reduction can mean $800 million in annual revenue lost industry-wide.
The connection between quality metrics and financial viability has never been stronger. But how does a health plan consistently ensure that thousands of complex members receive the timely, personalized care required to keep these metrics stable? The answer is clinical precision through value-based care models.
What is value-based care?
Value-based care (VBC) represents the healthcare industry’s critical shift away from the legacy fee-for-service (FFS) model. The FFS approach, which pays providers simply for the volume of services delivered, often rewards inefficiency and high cost.
Instead, VBC models directly tie financial incentives to measurable patient health outcomes, quality, patient experience, and overall cost efficiency. Under a VBC framework, success is defined by delivering the highest possible quality of care at the lowest sustainable cost.
While value-based care demands proactive, coordinated care, traditional in-house systems and manual processes are fundamentally ill-equipped to meet these goals:
- Fractured care delivery: Traditional models often lack the integrated technology to consistently track and intervene across a patient's entire journey, leading to care gaps and communication failures, especially for complex, high-risk members.
- Capacity bottlenecks: In-house teams are often stretched thin, lacking the on-demand scalability needed to address sudden surges in need or consultation backlogs. This forces teams to react rather than proactively manage populations, directly undermining VBC goals.
- Focus on volume: Without specialized tools, resources are diverted to administrative tasks and high-volume, low-value interactions, failing to concentrate clinical expertise where it matters most: delivering personalized, high-impact medication therapy management.
The net effect of these traditional limitations is a systemic drag on performance. For health plans, success in VBC is measured by two critical factors: improving the health of members, for example, by boosting medication adherence and enabling better chronic disease management, and lowering the total cost of care, which includes reducing expensive emergency room visits and readmissions. Manual, traditional approaches simply can’t consistently deliver on either factor at scale.
Value-based care models and CMS quality measures
The strategic goals of value-based care, improving patient outcomes and controlling costs, are enforced by major regulatory bodies. The Centers for Medicare & Medicaid Services (CMS) and other payers are the principal drivers of this transformation, demanding unwavering accountability from health plans.
For health plans operating in this landscape, performance is measured against two essential mandates that underpin all VBC success:
- Elevating member health: Ensuring proactive management of chronic conditions, significantly boosting medication adherence, and reinforcing essential preventive care.
- Controlling the total cost of care: Strategically avoiding expensive downstream interventions, such as unnecessary emergency room visits and preventable hospital readmissions that result from unmanaged, complex conditions.
VBC Metrics and High Stakes
Every health plan's viability and financial stability are assessed against specific, critical benchmarks. These metrics serve as the guardrails for VBC accountability and carry immediate and serious financial repercussions.
- Star ratings: This critical CMS rating system is directly impacted by a plan's performance on measures related to patient safety, medication management, and positive member experience. A drop in Star Ratings can lead to substantial financial losses and enrollment challenges.
- HEDIS (Healthcare Effectiveness Data and Information Set): These are the comprehensive performance measures that gauge how well a plan provides effective preventive and evidence-based care, targeting key gaps in treatment and monitoring.
- CAHPS (Consumer Assessment of Healthcare Providers and Systems): These surveys track member satisfaction and loyalty, proving that positive patient engagement is now a direct metric of quality.
Failing to meet or exceed these quality benchmarks puts both financial incentives and contractual obligations at significant risk. Achieving consistent, top-tier VBC performance requires a fundamental change in operational strategy, one that utilizes a scalable, proactive strategy and consistently connects patients with specialized clinical experts.
How pharmacy impacts value-based care models
The pharmacist is the most accessible and underutilized clinical asset in the transition to Value-Based Care. As medication experts, they are uniquely qualified to close the critical care gaps that directly undermine VBC performance. By shifting pharmacists from transactional roles to clinical interventions, health plans can drive measurable improvements across the entire spectrum of quality measures.
Medication adherence
Medication adherence is a critical factor that impacts both CMS Star Ratings and HEDIS performance. Pharmacists directly address this challenge by moving beyond simple refill reminders and providing exceptional value through:
- Identifying barriers: Pharmacists conduct in-depth, comprehensive medication reviews (CMRs), identifying patient-specific barriers such as cost, complex regimens, side effects, or a lack of health literacy.
- Personalized care: Through focused consultations, they reinforce the value of therapy and provide clear, empathetic instructions, leading to stronger patient understanding and commitment.
- Positive behavior change: This personalized, clinical engagement is far more effective than automated reminders, demonstrably boosting adherence rates and directly improving Star measures for conditions like diabetes, hypertension, and cholesterol management.
Chronic disease management
Successful value-based care relies on effectively managing high-risk populations with multiple chronic conditions. These are the members whose unmanaged care leads to the highest cost of care. Pharmacists intervene strategically by:
- Optimizing medication therapy: They work within the care team to review and adjust complex drug regimens, identifying and resolving drug-drug interactions, therapeutic duplication, and sub-optimal dosing.
- Closing care gaps: Pharmacists ensure patients are up-to-date on essential preventive screenings and necessary medication titrations, directly supporting key HEDIS benchmarks.
- Sustained support: For patients with conditions like diabetes, their frequent, accessible consultations provide the consistent clinical oversight needed to maintain control, preventing small issues from escalating into expensive acute events.
Patient safety
Reducing adverse drug events (ADEs) is a key factor of patient safety and a core metric in quality assessments. Pharmacists mitigate risk before it reaches the emergency room:
- Comprehensive medication review: Pharmacists conduct thorough CMRs to spot potential interactions and identify patients at high risk for falls, confusion, or hospitalization due to medication issues.
- Simplifying regimens: For seniors with polypharmacy, pharmacists consolidate prescriptions and provide clear instructions, significantly reducing the risk of accidental misuse or non-adherence.
- Reducing readmissions: By providing detailed medication reconciliation upon hospital discharge, pharmacists provide continuity of care, which is vital to reducing readmissions. In fact, VBC approaches are attributed to a 28% reduction in hospital admissions.
Cost savings
Every pharmacist intervention is an investment in prevention. By focusing on adherence, safety, and proactive management, pharmacists create a measurable return on investment for health plans:
- Preventing high-cost events: Improved adherence and safety directly translate to fewer emergency department visits and hospital stays, dramatically lowering the total cost of care.
- Optimized utilization: Pharmacists ensure patients are on the most effective and cost-efficient therapies, reducing waste and guiding appropriate drug utilization.
The clinical expertise of even the most skilled pharmacist is limited by time and capacity. To fully realize this measurable cost-saving potential across an entire member population, health plans must integrate the necessary technology to enhance the impact of pharmacists.
Pharmacy SaaS as a value-based care engine
While the clinical expertise of the pharmacist is non-negotiable for value-based care success, it’s pharmacy SaaS technology that transforms this expertise into a scalable, measurable, and reliable engine for performance. Modern digital platforms move pharmacists beyond limited capacity and fragmented workflows, providing the infrastructure to proactively manage entire member populations.
A dedicated pharmacy SaaS solution acts as the strategic backbone for value-based care, addressing the systemic failures of traditional models by ensuring clinical excellence can operate at an operational scale.
1. Technology-driven efficiency and scale
The central challenge in value-based care is simultaneously delivering high-quality, personalized care to thousands of members.
- On-demand capacity: Unlike fixed in-house teams, a SaaS model allows health plans to tap into a vast, nationwide network of remote pharmacists. This provides instant, on-demand scalability to eliminate consultation backlogs and meet tight regulatory deadlines, especially during high-pressure periods.
- Integrated workflows: The technology streamlines the entire care delivery process, from member identification to consultation documentation. By automating administrative tasks, the platform allows pharmacists to practice at the top of their license, maximizing time spent on meaningful clinical interactions.
2. Intelligent, precision matching
A major advancement of pharmacy SaaS is the ability to make sure the right intervention happens every time. This precision is essential for driving predictable value-based care outcomes.
- Pharmacist-patient matching: Proprietary algorithms move beyond basic assignment. The technology intelligently matches patients with a pharmacist based on critical factors such as language preference, geographic proximity, and specific clinical expertise.
- Eliminating access barriers: By delivering care via secure, digital channels, the platform eliminates traditional barriers like transportation, time constraints, and geographic isolation. This directly supports health equity goals and ensures vulnerable populations receive the consistent care required to close HEDIS and Star Rating gaps.
3. Real-time data and continuous quality improvement
Value-based care demands continuous measurement and immediate action. The integrated nature of a SaaS platform provides the necessary feedback loop:
- Actionable insights: Telepharmacy platforms provide health plans with real-time data on consultation completion rates, adherence improvements, and documented clinical outcomes. This visibility allows plans to quickly pivot strategy and target specific measures that are falling behind.
- Proof of value: Every pharmacist interaction is tracked and reconciled with quality metrics. This data provides the concrete evidence needed to demonstrate regulatory compliance and show the measurable return on investment required to sustain high-quality care and achieve CMS Star Ratings.
By implementing pharmacy SaaS solutions, health plans transition from a reactive, limited system to a proactive, data-driven value-based care engine that optimizes care spend, boosts critical quality scores, and ultimately strengthens member trust and loyalty.
Pharmacist-led care within value-based care models
The critical need for medication adherence, expert chronic disease management, and the pursuit of health equity all converge on the same essential infrastructure: a modern, pharmacist-led care delivery engine. With value-based care models, health plans and pharmacists are positioned to piece back together a fractured system by leveraging specialized clinical expertise amplified by scalable technology.
Aspen RxHealth specializes in providing health plans with the capacity, clinical precision, and technological enablement required to thrive with value-based care models. We transform the challenge of accountability into a sustainable competitive advantage:
- Scaling clinical excellence: To address capacity bottlenecks and sudden surges in demand, health plans can utilize Alliance by Aspen RxHealth. This delivery model provides immediate access to our nationwide, on-demand community of skilled remote pharmacists. It acts as the ultimate engine for rapidly closing care gaps, ensuring that every member receives a high-quality consultation without overstretching internal teams.
- Improving patient outcomes: Achieving top-tier value-based care demands precision. Alliance by Aspen RxHealth is powered by BeWell with Aspen RxHealth, which provides cutting-edge technology for intelligent MTM. This system strategically matches patients with the right pharmacist based on language, clinical specialty, and cultural fit. This level of personalized, high-value care directly boosts Star Ratings, enhances CAHPS scores, and solidifies member trust for the long term.
By partnering with Aspen RxHealth, health plans are empowered to move beyond simply meeting compliance standards. They can achieve measurable improvements in all critical CMS quality metrics and lay the foundation for a resilient, outcome-driven future. Book your demo today to get started!
