Greater Boise home-LTC pharmacy economics
A working pro forma for an LTC pharmacy serving frail, dual-eligible members at home under a value-based contract with Molina or UnitedHealthcare via Idaho's MMCP. Adjust assumptions to match your negotiated rates.
What this calculator does
It models one thing: whether a value-based contract between an Idaho MMCP plan (Molina / UHC) and a home-LTC pharmacy can work for everyone: the plan, the pharmacy, and Home LTC.
It does not model Part D drug sales. Pills are still paid through normal Part D claims. This is about a separate monthly fee the plan pays the pharmacy for packaging, delivery, and clinical services, plus optional shared savings.
The plan's savings number comes from a published study (ExactCare, 2021). You don't slider that. You slider the contract terms and see if the math works.
Two separate money flows (don't mix them up)
Rail A: not in this calculator
Part D drug claims
The plan pays for prescription drugs the normal way (NCPDP / Part D). The study found this goes up ~$30/member/mo when people get better adherence: more fills, fewer gaps.
This is already baked into the plan's net savings below. It is not the Services PMPM.
Rail B: what you're modeling
Services contract (PMPM)
The plan pays the pharmacy a flat monthly capitationfor high-touch work Part D doesn't cover: blister packaging, home delivery, pharmacist visits, MTM, reporting.
Default: $125/member/mo ← you adjust this
Step 1: Pick a scenario
How many frail dual-eligible members in Greater Boise (Ada + Canyon) are on the pharmacy program?
Step 2: Set contract terms
These are negotiated between the plan and pharmacy. Nothing here is published; defaults are placeholders.
Plan → pharmacy monthly capitation for packaging, delivery, clinical (Rail B)
Pharmacy gets this % of the plan's $226/mo medical savings (study)
Pharmacy licenses the Home LTC software at an FMV rate set in advance — not a share of the plan's savings
The answer (at current settings)
Annual totals for 400 attributed members in Greater Boise.
Health plan
Net savings after paying pharmacy
$178,080 / year
$37/member/mo × 400 members
LTC pharmacy
Net profit after ops + platform
$431,720 / year
$90/member/mo × 400 members
Home LTC
Platform revenue
$48,000 / year
$10/member/mo × 400 members
Follow the money: one member, one month
This is the same math as above, but for a single member so you can see each line item. Study numbers are fixed; contract numbers come from your sliders.
Health plan
Molina or UHC MMCP, at risk for total cost of care
From ExactCare study (fixed)
−Medical costs go down (hospital, SNF…)
Observed in JMCP 2021 study
+Part D drug spend goes up
Separate rail: normal Part D claims, not Services PMPM
Net TCOC improvement
226 − 30 = 196. This is what funds the deal.
Contract payments (your sliders)
−Pays pharmacy: Services PMPM
−Pays pharmacy: shared savings (15% of $226 medical)
Plan keeps
LTC pharmacy
Receives contract revenue, runs the program
Money in
+Services PMPM from plan
+Shared savings from plan
Money out
−Variable ops (packaging, delivery, clinical…)
−Fixed program cost (÷ members)
−Platform fee to Home LTC
FMV software licence (roster sync, PDC/quality reporting, services billing) — set in advance, not a cut of savings
Pharmacy keeps
Home LTC platform
Paid by pharmacy: roster ingest, PDC/quality reports, services billing
+Platform fee from pharmacy
−Indicative hosting (Neon + Vercel HIPAA)
~$5.4K/yr, see docs/hipaa-hosting.md
Platform keeps (fee − hosting only)
Excludes salary / eng
Where do the members come from?
Greater Boise (Ada + Canyon). The funnel narrows to frail dual-eligibles who qualify for institutional-level pharmacy at home.
Sources & caveats
- TCOC savings ($196/mo): ExactCare JMCP 2021: $196 PMPM total cost reduction (observational). Observational, company-affiliated, directional only.
- Medical savings ($226/mo) and drug increase (+$30/mo): ExactCare JMCP 2021: +$30 PMPM prescription drug spend. Drug increase is Part D, not Services PMPM.
- Services PMPM ($125/mo): Not published, a placeholder for negotiation.
- Population: SSA OASDI Beneficiaries by County, Dec 2024 (Ada + Canyon, aged 65+). Idaho DHW / CHCS: ~28–30k integrated duals statewide (MMCP + IMPlus). Ada + Canyon ≈ 39% of Idaho population; ~40% dual share (urban skew).
- Part D dispensing fees and drug ingredient margin are excluded from this model entirely.
Assumptions & limits
- Geography: Boise–Nampa MSA core = Ada + Canyon counties. Does not include Twin Falls, Coeur d'Alene, or rural eastern Idaho.
- Population: 122,700 residents 65+ (SSA Dec 2024). ~12,000 integrated duals estimated at 40% of Idaho's ~30,000 dual population, with urban concentration in mandatory managed-care counties.
- Program eligibility: ~45% of metro duals assumed to meet institutional-level-of-care-at-home criteria (HCBS waiver, polypharmacy, ADL needs). Not all duals qualify.
- Payer value: ExactCare JMCP 2021 study ($196 PMPM medical savings, +$30 drug). Observational, company-affiliated, directional only.
- Contract rates: Services PMPM and shared-savings percentages are not published. Defaults ($125 PMPM, 15% shared savings) are placeholders for negotiation modeling.
- Excluded: Part D drug ingredient margin, C-SNP non-dual chronically ill members, and dispensing-fee-only economics (refuted as reliable path in market research).