The therapy has to reach the person.

Start with the unresolved medication decision

My pharmacy strategy begins with a practical question: what prevents this person from carrying out the agreed treatment plan? The answer may be clinical appropriateness, contradictory instructions, affordability, a benefit restriction, a dispensing constraint, a language barrier or the person’s own preference. These are distinct problems. A refill reminder is unlikely to solve all of them.

I would organize the pathway around the next decision and the professional authorized to make it. A coordinator can resolve an access exception. A pharmacist can review the regimen within scope. A prescriber can change treatment. The operating system should connect those actions without confusing their authority.

Read the evidence beyond the savings headline

My investment conclusion is to specify the benefit being purchased. Medication safety, patient understanding and a more reliable transition can justify a service even when a readmission claim is unsupported. Those benefits need their own measures, staffing requirements and price. A null utilization result should improve the investment thesis rather than disappear from it.

Build the four linked workstreams

Proposed pharmacy operating design; no specific therapy recommendation
Workstream	Operating question	Completion evidence
Appropriateness	Is the intended regimen reconciled with clinical judgment and the person’s goals?	A reviewed medication plan and ownership of unresolved discrepancies.
Access	Can the person obtain the intended therapy through a viable benefit and delivery route?	The access barrier is resolved or a clinically appropriate alternative is considered.
Use and understanding	Can the person explain and implement the agreed plan?	A meaningful conversation, appropriate support and confirmation of remaining difficulties.
Monitoring	Who acts on nonresponse, possible harm or a changing regimen?	An agreed follow-up and a documented clinical response when needed.

I would keep prescription, dispensing, claim payment, possession, use and response as separate states. A claims-derived adherence measure is an operational proxy; it cannot establish why a gap exists or whether continuing a medicine is clinically appropriate. The person’s explanation and the clinical record remain necessary.

Make deprescribing a care process

My strategic position is that the target should be appropriate treatment with an agreed monitoring plan. Paying for discontinuation volume can create the wrong incentive, just as rewarding dispensing volume alone can. The pathway needs patient agreement, prescriber accountability, communication across settings and a way to revisit the decision.

Reconcile the economics across the benefit boundary

For a payer, medical and pharmacy spending are connected but cannot be netted together through an assumed offset. For a pharmacy or clinical service business, revenue depends on the actual contract, acquisition and delivery cost, workforce, payment adjustments and cash timing. For the person, out-of-pocket expense and practical access may dominate the decision. I would show all three views.

A proposed service contribution model is contracted service revenue minus pharmacist and support labor, technology, follow-up and allocated operating cost. Drug economics belong in a separate ledger when the business also dispenses. Shared-savings payments require their own settlement bridge. Mixing these streams makes a profitable transaction look like a proven health benefit.

Medicare Part D medication therapy management has a defined program framework and annual sponsor requirements. That framework is one possible operating context, not a universal payment entitlement for every pharmacy activity. Contract-year requirements and the specific agreement must determine the delivery and revenue model. [3]

The executive decision

I would fund the pharmacy capability that resolves the most consequential break in the care pathway, then test it under real operating conditions. The scorecard should show access, clinically reviewed discrepancies, patient experience, follow-up, workforce burden and full delivery cost. Any claim about hospital use or total spending needs an appropriate comparator.

This is where pharmacy becomes infrastructure: the organization can explain which medication decision was made, who owns the next step, whether the person could implement it and what remains unresolved. That is a stronger strategic position than another isolated engagement tool.

Sources and scope

Selected primary studies and official references reviewed September 27, 2026. Research findings are attributed to their authors; the operating proposals and strategic interpretations are original synthesis. This article does not claim that these proposals constitute a tested bundle or personal implementation record.