Pharmacies

Why Pharmacists Play a Critical Role in the Health of Diabetes Patients

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Appropriate products and services impact medication adherence and tie together a coordinated approach to managing the potentially devastating, costly disease.

Nearly 30 million children and adults in the United States have diabetes, and 1.4 million Americans are diagnosed with the disease every year.1 Complications of diabetes include higher hospitalization rates for heart attack and stroke, and it has emerged as the leading cause of new cases of kidney failure.2 An estimated economic burden topping $320 billion stems from diagnosed and undiagnosed diabetes, prediabetes and gestational diabetes.3 In total, the U.S. spends 20 percent of healthcare dollars caring for people with diabetes.4

Medicare and other insurers recognize the high incidence of diabetes and its potentially debilitating outcomes. Accordingly, healthcare professionals must understand how to better prevent and treat the disease — and how to reduce the costs associated with it.

Pharmacies are an essential part of that equation as the market shifts toward pay-for-performance models. Those that succeed will be aligned with health plans’ scoring mechanisms that demonstrate their work in creating healthier patients. They’ll also be positioned to maximize revenue opportunities beyond traditional diabetic medication dispensing.

Guidelines and measures
For 2016, there is no active clinical quality measure for diabetes therapy under the Medicare Star Ratings system for insurance plans. But changes are on the way.

In 2015, guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) recommended moderate to high-intensity statin therapy for primary hypertension prevention for persons aged 40-75 with diabetes. That recommendation was adopted by the American Diabetes Association.5

The Pharmacy Quality Alliance (PQA) subsequently developed a new diabetes treatment measure based on the ACC/AHA recommendation. The measure, which reflects the percentage of diabetic patients aged 40-75 who are receiving at least two fills of statin therapy, is a display measure only for years 2017 and 2018 of the Star Ratings program (based on data from 2015 and 2016).

That means pharmacies can view the measure on their current EQuIPP® performance reports, but it is not an active measure within the Star Ratings program — yet. Note that PQA intends to add it as an active clinical quality measure for statin therapy in diabetes patients to be used for 2019 Star Ratings (based on 2017 data).

The current national average is 68.7 percent of diabetics aged 40-75 who are receiving at least two fills of statin therapy. The EQuIPP® goal is to exceed 79.2 percent.

At the same time, there are several active Star Ratings performance measures that pertain to diabetes patients:

D12 Medication Adherence for Diabetes applies to all oral and injectable diabetes medications but excludes insulin. Medications monitored are biguanides, sulfonylureas, thiazolidinediones, DPP-IV inhibitors, incretin mimetics, meglitinides and SGLT2 inhibitors. According to 2016 Star Ratings data, Medicare Advantage plans with prescription drug coverage (MA-PD) averaged 77 percent on this measure (in line for a 4 Star rating), while prescription drug plans (PDP) averaged 80 percent (3 Star rating).6

D13 Medication Adherence for Hypertension measures angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB) or renin angiotensin system antagonist (RASA) medications, with an adherence threshold of 80 percent of patient days covered (PDC). The 2016 Star Ratings MA-PD average was 79 percent (4 Star), while the PDP average was 82 percent (3 Star).7

D14 Medication Adherence for Cholesterol measures statin therapy, again with an 80 percent PDC threshold. The 2016 Star Ratings MA-PD average was 75 percent (4 Star), while the PDP average was 78 percent (3 Star).8

D15 MTM CMR Completion Rate measures the percent of medication therapy management (MTM)-eligible enrollees who received a comprehensive medication review (CMR) during the reporting period. Diabetes is the top targeted condition for this measure. MA-PD plans averaged 30.9 percent of CMR cases completed (2 Star) for the 2016 program, while PDP plans averaged 15.4 percent (2 Star).9

After all, diabetic patients that take diabetic medications are likely to be on an ACEI or ARB, and those aged 40-75 are recommended for statin therapy.

Pharmacy opportunities
Effectively managing diabetes medication adherence not only positively impacts the pharmacy’s Star Ratings but the organization’s bottom line as well. And, most importantly, a coordinated approach to diabetes management improves the health of patients.

Medication synchronization, the process of coordinating all of a patient’s chronic medications to be filled at the same time each month, should be a key component of the pharmacy’s holistic diabetes strategy. These patients need to remain adherent to stay healthy. What’s more, a study conducted by the National Community Pharmacists Association found that synchronization adds an average of more than three refills per prescription per year.10

Additionally, the MTM CMR service, completed once annually, is a unique opportunity to encourage healthy habits among diabetic patients, thereby strengthening the bond between patient and pharmacy.

Pharmacists should also recommend that diabetes patients receive vaccinations for influenza, pneumonia and shingles.

Other diabetes-related products can help lock in patient relationships, too. Consider offering glucometer supplies; over-the counter therapies such as glucose tablets/gels, foot creams and vitamin supplements; special socks that can prevent foot infections; compression stockings to prevent or control edema; and therapeutic shoes with multi-density orthotic inserts.

In all these areas, the pharmacy team should develop a mindset for offering appropriate products and unique services for diabetes patients. Keep in mind that pharmacists and staff need to be experts in all offerings and must be able to educate patients on their use in clear terms.

Best practices
Moundsville Pharmacy, where I practice, proactively reaches out to diabetic patients by assessing the products and services that relate to their condition. The following tips, gathered from our experience, can be adopted and adapted according to a pharmacy’s needs and capabilities:

  • Utilize checklists. Make a list of pharmacy products/services and have it readily available during patient interventions. This list reminds the pharmacist to convey to the patient potential health benefits or reduced health risks associated with each offering. When the pharmacist counsels on a new medication, for example, he or she may add comments about vitamins or supplementation products specially designed for diabetes patients. From a business perspective, this type of exchange also opens up opportunities to create additional revenue.
  • Develop educational materials. Patients can’t absorb everything during a brief consultation. Provide written recommendations so that patient can later review suggested products or services and evaluate their appropriateness in concert with family members or caregivers.
  • Regularly target different services or products. Train staff and utilize written materials to cover specific offerings on a monthly basis. Reinforce that whenever diabetes patients enter the pharmacy during January, for instance, everyone should be prepared to recommend compression stockings and distribute appropriate take-home information. When the calendar flips to February, choose another product or service to highlight during the month, and so on throughout the year.
  • Actively communicate with prescribers. The pharmacist may not be familiar with the full scope of a diabetes patient’s diagnosis. In such a case, particularly if the patient seems hesitant about a product or service, offer to call the prescriber to confirm his/her support for the pharmacy’s recommendation.
  • Be prepared to deliver. Stand ready to complete the sale when a patient accepts the pharmacist’s recommendation. That may mean implementing standing orders for immunizations, assembling informational packets for therapeutic shoes, or stocking inventory with common sizes of socks and stockings, to cite a few examples.
  • Continuously make progress. Many pharmacies find it helpful to gradually introduce new offerings, allowing enough time for the entire team to get comfortable when discussing each product line and pharmacy solution. In any case, it’s important to track accepted recommendations and recognize successes (e.g., by bringing in lunch or paying monetary bonuses for achieving predetermined goals). Find a model that motivates and rewards the pharmacy team, and then apply it to as many products and services as practical.

Don’t be left behind when it comes to caring for diabetic patients. Be prepared to counsel them on how unique pharmacy products and services can help them manage their disease and improve their health. Then follow through by delivering the appropriate offerings and monitoring progress and outcomes.

References
1. American Diabetes Association. Fast facts: data and statistics about diabetes. Updated December 2015. http://professional.diabetes.org/sites/professional.diabetes.org/files/media/fast_facts_12-2015a.pdf
2. Ibid.
3. Ibid.
4. Ibid.
5. American Diabetes Association. Diabetes care: cardiovascular disease and risk management. http://care.diabetesjournals.org/content/38/Supplement_1/S49
6. Pharmacy Quality Alliance. Update on medication quality measures in Medicare Part D plan Star Ratings – 2016. http://pqaalliance.org/measures/cms.asp
7. Ibid.
8. Ibid.
9. Ibid.
10. Patients benefit from pharmacy-provided medication synchronization programs. http://www.ncpanet.org/newsroom/news-releases/2014/01/15/patients-benefit-from-pharmacy-provided-medication-synchronization-programs
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