“This is going to end,” Carter said of the arrangements that push up list prices of insulin and out-of-pocket costs for many diabetes patients.
The implications of these sometimes prohibitive costs, among other issues, is considered in the following Chain Drug Review roundtable on diabetes care. The participating retail executives and suppliers discuss how pharmacists are positioned to affect multiple facets of the way people cope with diabetes, pointing them, for instance, to healthy food choices as well as providing diabetes care products and services. Being among the most trusted professionals in the nation, their capacity to educate patients is invaluable. Bolstering their efforts are digital advances helping patients monitor their management of diabetes. Experts see the potential of such technologies as virtually unlimited.
CDR: With the price of insulin in the news, what can suppliers and retailers do to keep the overall cost of diabetes care affordable?
Brennan: Diabetes affects 30 million children and adults in the U.S., according to the ADA. Another 84 million Americans have prediabetes and are at risk for developing type 2 diabetes. In addition to the physical toll diabetes takes on people — including serious health complications like stroke, blindness and kidney disease — the economic costs are staggering.
Over the last three years, we’ve seen list prices for insulin increase nearly 50%. Given the high prevalence of the condition, the cost burden on our nation’s health care system is significant. For every $7 spent on health care, $1 is spent on diabetes care. And people with diabetes have health care costs that are 2.3 times greater than those without diabetes.
The primary challenge we face is that, unlike most other drug classes, there have been no generic alternatives available, even though insulins have been on the market for more than 30 years. So, CVS Health has taken a number of steps to address the impact of insulin price increases.
First and foremost, we negotiate the best possible discounts off the manufacturer’s list price on behalf of the employers, unions, government programs and beneficiaries that we serve. Our analysis indicates that in 2018 we were able to reduce the total cost of diabetes drugs, including insulin, by 1.7% despite brand price inflation of 5.6%. And, importantly, patient adherence has increased.
CVS Caremark, our pharmacy benefits manager, has long provided our clients with plan design options that enable them to set low or fixed co-pays for select drugs or classes of drugs that treat common chronic diseases such as diabetes. We also advocate that clients add insulin and other antidiabetic medications to the Preventive Drug List (PDL) and make them available to members at a $0 co-pay, a strategy we employ with our own employees and make available to our clients.
CVS Health also supports comprehensive care management programs that engage our patients and members to encourage healthy eating, exercising and blood glucose level monitoring and to counsel them on the proper use of, and adherence to, medication. This strategic approach of early detection and disease management supports better diabetes-related outcomes and helps to control costs by reducing expenses associated with acute, in-patient hospital treatment and disease progression.
Kerley: Diabetes affects almost all aspects of patients’ lives. Pharmacists can change the lives of these patients. We can make it easier to manage their disease by providing education, screenings, immunizations and medication therapy management services such as adherence counseling and addressing gaps in care. All of these efforts can improve outcomes and help ensure that patients appropriately manage their medications and remain adherent to their therapies, which in turn controls cost and prevents hospital or urgent care visits.
Shah: Adherence to medications is a critical way to improve health outcomes, which ultimately helps to drive down costs for patients, providers and the health care system. That’s why we’re invested in increasing adherence through awareness and education programs, as well as a suite of tools and services to make taking medications convenient and accessible. Our services like Save-a-Trip Refill, 90-day refills and Walgreens Express Delivery are all important tools to help ensure patients take their medication as prescribed, which ultimately helps drive down costs. Additionally, we believe collaboration and price transparency are critical to lowering costs. Our pharmacists routinely suggest lower-cost generics to ensure patients get the best value and most appropriate prescription medications. We’re also rolling out new digital tools that streamline communication between pharmacy and prescribers to facilitate the approval of lower-cost alternative medicines, so our patients can access the medicines they need.
Pflieger: Although health care costs continue to climb, finding ways to control the overall costs requires understanding the underlying triggers that are driving up costs. A look at insulin pricing illustrates just how convoluted this can be. The money exchanged between manufacturers, distributors, buying groups, managed care organizations, PBMs and pharmacies are so layered with rebates and fees that cost transparency is blurry at best. Although on the surface increases in the price of injectables sound staggering, these figures don’t necessarily tell the full story. For example, they do not isolate the potential impact on patient co-pays, assess the influence of increased rebate payouts or factor in how reimbursement may be affected.
Rather than discuss a radical change to the distribution models for drugs and devices, let’s focus more generally on strategies to improve patient treatment adherence. Patients who are highly compliant to their treatment regimen are less likely to be hospitalized or rehospitalized for severe hyperglycemic and hypoglycemic episodes or for diabetes-related comorbidities, and this reduces the financial burden on health care systems as well as on a patient’s own pocketbook.
The short answer to the question posed is that suppliers and retailers can reduce overall costs by focusing their attention on patient compliance. Improving patient compliance sounds simple, but like many things in health care it is actually quite complex. Patient adherence demands a multifaceted approach, and the human element remains the most complex part of the compliance equation. People stop or delay taking medication for different reasons. Some may be forgetful and require a gentle reminder, and for others cost is a primary driver. Many may not comprehend the gravity of their condition and don’t take adherence seriously — and lack of convenience, transportation or access to products may also represent barriers.
Automated programs like prescription reminders or point-of-sale messaging have been shown to help adherence. When patients are naive to the seriousness of their disease or feel they cannot afford their treatment, patient education, product selection and cost-saving programs must not be understated. Cost plays an especially critical role in treatment compliance, thus retailers should ensure staff are well versed on product pricing, cost-reduction programs and cash price versus insurance co-pays. Patient education is critical too, since efforts to reduce costs like medication rationing and device reuse can cost significantly more in the long run when these result in hospital stays and emergency room visits.
Products themselves may have an impact too. When Unifine Pentips Plus launched in the U.S. market, we were one of a few manufacturers leading the dialogue on patient adherence. Through thoughtful design features that addressed injection therapy obstacles, Owen Mumford brought to market a product that made injection therapy easier, safer and more convenient for patients. In doing so, patients were more likely to comply with a healthy injection routine.
Rajora: What might not be obvious as driving medication compliance is the single most impactful way to reduce the overall cost of managing diabetes. Well-established clinical studies show that taking diabetes medicines as prescribed significantly reduces the acute episodes and health complications associated with diabetes, both of which are very expensive. Keeping blood sugar in control through medication, diet and exercise is much less expensive than emergency room visits or managing associated comorbidities.
For individuals who struggle with being compliant due to the ongoing affordability of managing diabetes, there are new alternatives being offered by both drug and device manufacturers. These alternatives are being led by retailers and PBMs engaging in direct relationships with novel original manufacturers on finding alternative ways to provide high-quality care at lower costs. For example, our Droplet line of pen needles and syringes has paved an attractive path where, by collaboration across the PBM-manufacturer-retailer continuum, costs are significantly reduced for the health care system, payors and patients. This has unlocked resources to invest in innovative diabetes programs delivered via the pharmacy aimed at driving compliance. When all stakeholders have been engaged, we have a demonstrated instance where Droplet reduced costs by 60% while providing the highest-quality product and diabetes education to patients. This multi-stakeholder collaboration keeps costs down for patients and supports better health outcomes with investment into both pharmacy programs and individualized patient care.
CDR: Pharmacists may be the most economical professionals for helping people monitor diabetes. How can their accessibility and knowledge best be highlighted for patients?
Shah: Diabetes patients rely on a pharmacy they trust and knowledgeable pharmacy staff to help manage their diabetes. Most pharmacists see their diabetes patients more often than any other health care provider, and they are an important part of patients care ecosystem. As some of the most accessible providers in a care team, pharmacists should work with patients’ broader health care team and help other providers understand the value and knowledge that they can bring patients’ holistic care.
Additionally, it’s important that pharmacists are participating in local community events and organizations to raise awareness of the care and services they can provide. Our pharmacists participate in community outreach programs. As part of these, we offer presentations on diabetes care and solutions.
Houston: Diabetes affects 30.3 million Americans, or 9.3% of the U.S. population, and it can be a major medical expenditure as it requires patients to undergo significant changes to their daily health and lifestyle routines. For many, this includes proper medication therapies, blood glucose management, healthy diet and exercise. As diabetes regimens become more complex and involved, patient counseling by health care professionals has become imperative.
Because pharmacists are the most accessible point of care and have strong patient relationships, they are often best positioned to help support members of their community with chronic conditions. Consider the counseling opportunities available as a pharmacist often sees his or her patients 35 times per year, while a patient may only visit their primary care physician three or four times in the same time frame. Pharmacists have the ability to build the relationships with patients necessary to influence behavior — not only for critical medication adherence support, but also to counsel on lifestyle changes that may be required long term.
Through increased transparency and communication, pharmacists can foster better relationships and trust with their patients. Resources like AmerisourceBergen’s Good Neighbor Pharmacy app, My GNP, can provide pharmacists with greater access to their patients and further spread their knowledge. Through the My GNP app, patients can view educational articles, set reminders to take medicine, schedule refills and designate a “med buddy” to help stay adherent right from their mobile device. Pharmacists can also promote adherence by scheduling regular check-ins and communicating directly with their patients through the app or other patient-preferred channels, such as text messaging. Pharmacists can time these communications with moments of anticipated adherence challenges, such as when certain side effects are likely to be present, to best support patients and reinforce the need for continued medication use.
Beyond targeted communications, pharmacists can also connect with patients simply by sharing their knowledge and maintaining a strong presence online — whether that’s on their website, via social media or in Google search results. For example, pharmacists can customize their own local page on our recently redesigned patient website, MyGNP.com, with staff photos, store news and information about the services they provide. This not only makes it easier for patients to learn more about their pharmacy but also gives patients direct access to health and wellness articles on a variety of topics, including diabetes, heart disease, asthma and more.
Ultimately, one of the greatest differentiators of pharmacists is their personal patient connection, and using a variety of tactics to engage their patients gives them more opportunities to demonstrate their value and develop deeper relationships within their community.
Pflieger: Community pharmacies are ideal platforms for ensuring continuity of care for chronic disease management, like diabetes. Patients living with diabetes already visit their pharmacy at least once a month to purchase medication and supplies, and because pharmacies tend to be more regionally focused with staff who often share similar ethnic and cultural backgrounds, patients may find it easier to communicate with their local pharmacy staff.
Despite pharmacies having longer hours of operation and no prior appointments required, patients don’t often perceive their pharmacist as being easily accessible. The first step in highlighting the knowledge and accessibility of pharmacists is by promoting these capabilities. That can happen through in-store signage, prescription receipts and in conversations with other pharmacy staff. Yet, this can also be problematic when it interferes with the daily work flow needed to ensure prescription quotas are fulfilled. At the end of the day, a pharmacy is a business just as much as it is a health care destination, and it must be able to perform profitably or else it is unable to serve its patients.
Time is money, and reimbursement is key. By creating Diabetes Self-Management Education (DSMD) programs in accordance with American Diabetes Association (ADA) best practices and national standards, pharmacies can seek out reimbursement through federal and state programs, and possibly through private payors. Such programs allow pharmacists to maximize their impact, without sacrificing business needs. Merchandising can also help improve efficiency, as can cross-training other pharmacy staff to handle less complex questions. End-caps focused on diabetes management (including “staff picks”) may help speed up consults, while also increasing O-T-C sales.
Brennan: As our nation’s health care landscape evolves, pharmacists are being called upon to play a broader role in improving access to care and lowering costs for patients. At CVS Health, our pharmacy teams are leveraging technology, integrated clinical information and their medication expertise to play an increasingly important role in identifying medication adherence barriers and solutions for patients.
Our diabetes programs are rooted in care management and personalized pharmacist support. Our pharmacists not only provide one-on-one trusted counsel to patients daily, they also deliver vital health care services, such as offering medication reviews to ensure patients are getting the most out of their medicines.
Introduced in 2017, our Transform Diabetes Care program, the first in a suite of Transform Care programs focused on managing costly, chronic conditions, expands the diabetes programs and services already provided by CVS Health. Transform Diabetes Care helps CVS Caremark clients improve the health outcomes of their members and lower pharmacy costs through medication management, blood glucose control and healthy behavior/lifestyle change.
By bringing together remote monitoring technology with CVS Health local points of care, the program is uniquely enabled to stay in close touch with members. For enrolled members, CVS Pharmacy pharmacists offer a private consultation to address medication management challenges, sign them up for a program-provided connected glucometer and provide interventions as needed. During MinuteClinic diabetes preventive monitoring visits, members receive recommended exams and tests to avoid complications and remain on track with their prescribed care plan between visits with their doctor. This one-on-one engagement right within members’ communities is key to the program.
The program is demonstrating positive impacts for our members and clients. Patients enrolled in the program improved their A1c by 1.2 percentage points at six months, and sustained that improvement at 12 months. Over 50% of members with uncontrolled diabetes saw their condition improve to controlled status, and 31% of all eligible members with diabetes signed up for a connected glucometer.
Rajora: Pharmacists may be the most economical professionals for helping people monitor diabetes. How can their accessibility and knowledge best be highlighted for patients?
Pharmacists are one of the most trusted and accessible health care professionals. As we’ve seen with immunizations and the opioid epidemic, when the industry works together, incredibly effective solutions with immediate impact can be realized. The Centers for Disease Control and Prevention (CDC) describes obesity as an epidemic in the U.S. with a prevalence of 39.8% in adults and 18% in children. By initiatives that promote health and wellness, pharmacists can prevent or support healthy lifestyles to reverse obesity, affecting not only diabetes prevalence and management but also other conditions such as heart disease and cancer.
Kerley: Patients have always relied on their community pharmacists to meet their health care needs. Rated as one of the most trusted, highly accessible health care providers, pharmacists are positioned to play a greater role in managing diabetic patient care.
The health care system must look to pharmacists for their role beyond filling prescriptions and involve them in the patient’s health care ecosystem. Patients with chronic conditions like diabetes can benefit from having personalized and frequent contact with their health care team, which pharmacists should be considered an integral part of. Rite Aid pharmacists are available to offer counseling and education for diabetes patients, educators and providers.
A major barrier that exists for pharmacists being able to provide more comprehensive care is obtaining provider status. The additional services and time spent assisting these patients to better manage their disease state and outcomes goes unpaid by third-party providers. Obtaining provider status for pharmacists will help increase the services pharmacists offer to assist these patients, such as HgA1c testing, medication management based on results, annual screening for diabetic neuropathy, and lifestyle and behavioral counseling.
CDR: How can retailers best raise consumer awareness of diabetes — and prediabetes?
Houston: Diabetes is often undetected, especially among patients who don’t receive regular medical checkups or don’t have an established relationship with a primary care provider. In fact, of 30.2 million adults with diabetes, 7.2 million are undiagnosed. To identify and prevent the progression of prediabetes, it’s important for pharmacists to educate all their patients, even those who are not at risk, currently on attributes and effects of the disease and the importance of a healthy lifestyle. In many cases, we’ve seen retailers further support their pharmacies by leveraging their own information channels, such as their own health publications, website, circulars, etc., to educate patients on how to detect and manage symptoms before they become severe.
We’re also seeing more and more pharmacists investing in value-based programs and turning towards strong partners for resources to properly educate their patients. For example, Good Neighbor Pharmacy supports member pharmacies with tools and resources to optimize business operation and performance, allowing pharmacists to focus their time on strengthening relationships with patients. Pharmacists with diabetic patients can access training and educational materials customized to address the intricacies of their patients’ conditions. We’ve also seen several members invite nutritionists into their stores to offer “office hours” to customers as an added value service — again, this is a service that appeals to both diabetic and nondiabetic patients and could help curb the progression from prediabetes to a chronic condition.
Pharmacists can also offer simple health screenings or blood glucose testing that not only helps with early detection but also drives awareness for diabetes and opens the door for further conversation.
Pflieger: Pharmacies interface with patients on a frequent basis and are uniquely suited to serve as an educational platform within their communities. In addition to providing free educational resources and consults, several of our customers host diabetes screening events, offering free or low-cost screening services throughout the year. These events are a powerful way to reach patients and broaden awareness, and the pharmacy can easily promote these events through in-store flyers, prescription receipts and physician networks.
Although diabetes screening events may not confer an immediate ROI, they have the potential to make a significant impact on the health and well-being of the local community. A great example of this is H-E-B. Their investment in the health and well-being of the local communities they serve fosters loyalty and retention, which makes the hard work and effort a sound business investment.
Although the pharmacy may be more economical than other health care platforms for reaching patients, it should be considered that pharmacies are businesses and cannot operate like a nonprofit clinic. Free or low-cost community initiatives can be expensive for a pharmacy to carry out and require thoughtful planning and patience. They often involve tools like safety lancets that aren’t regularly stocked by the pharmacy. That’s one of the ways we can provide even greater support to our partners. In addition to home-use diabetes care products, Owen Mumford manufacturers clinical products including safety lancets (Unistik) and can help offset some of the costs. Successful community pharmacies leverage their partnerships and networks to reduce costs, maximize reimbursement and promote their services. In turn they can provide value to their community and to their business.
Shah: Through their presence and access points in thousands of communities across the nation, retail pharmacies are uniquely positioned to play a key role in providing health care services and helping to educate consumers and patients on diabetes. In Walgreens stores, diabetes products and offerings are prominently positioned, and pharmacists are equipped with the expertise to answer questions and address concerns around pre-diabetes and diabetes. Outside of our stores, pharmacists regularly engage in community outreach and help raise awareness for diabetes and treatment options.
While personal interaction remains key, many of the touchpoints that pharmacies have with their patients are also online. Walgreens offers a wealth of information for diabetes patients and caregivers online on their website.
Rajora: CDC estimates 30.3 million Americans have diabetes and 84.1 million have prediabetes. The national diabetes prevention program states that structured lifestyle interventions can cut the risk of type 2 diabetes in half. The National Association of Chain Drug Stores estimates that 89% of the American population live within five miles of a community pharmacy. As such, being a neighborhood pharmacy, pharmacists will see families through their life cycle from young families to elderly populations. This affords pharmacies the unique opportunity to engage families for both prevention and treatment, in the pharmacy, through merchandising or marketing efforts, or outside the pharmacy such as through community engagement from schools to senior communities.
Kerley: To properly treat diabetes, education needs to be the foundation of care. Education should include medication therapy management, a true understanding of the disease and lab values, proper immunizations, weight management, exercise, nutritional choices, and proper testing. Pharmacists and pharmacies are uniquely positioned to offer resources to help patients successfully achieve lifestyle goals through services and product offerings at the pharmacy.
To raise consumer awareness, retailers can host wellness events for patients to receive blood glucose screenings, foot exams and information about how to read nutrition labels, ultimately promoting changes that lead to a healthier lifestyle.
Additionally, due to accessibility and the frequency in which they see patients, community pharmacists are available to counsel, educate and increase awareness of diabetes, thereby helping their patients lead healthier lifestyles.
Finally, at Rite Aid, our pharmacists team up with the Medicine Support Team (powered by Health Dialog). In addition to the in-person interactions our pharmacists have with these patients while in-store the Medicine Support Team provides follow-up calls. This additional outreach is conducted for patients with diabetes and other disease states to provide education and adherence support while encouraging them to refill their medications on time each month.
CDR: Discuss the capabilities of digital media and social networks for helping people track their diabetes management.
Shah: We see a tremendous potential in utilizing digital technologies to reach diabetes patients and support self-care. In particular, new technology platforms and connected care devices will bring many benefits in the near future. For example, Walgreens helps patients with diabetes make healthy decisions through our Walgreens app, where they can earn balance rewards points for healthy choices, and track their blood glucose levels and exercise activity.
It is well known that many patients look to online and social media to find answers to their questions and concerns. Walgreens is also looking at nontraditional ways to engage with social media influencers with diabetes as part of a national campaign to educate consumers on medication nonadherence and the risks associated with it.
Pflieger: It is an exciting time to be a part of diabetes care. Digital platforms are making closed loop (“artificial pancreas”) systems a reality. We are seeing the CGM (continuous glucose monitoring) and insulin pump data silos beginning to crumble, thanks in part to open-source altruistic platforms like Tidepool, and new disruptive distribution models. Leveraging data across digital media and social networks represents a huge opportunity, but it also presents risks. Questions remain as to what data is utilized, how information should be delivered and who should pay for it. On top of that there are privacy issues, the emergence of new technologies (like wearables) and heightened security concerns. This technology offers the most promise to insulin-dependent type 1 patients, but likely won’t be as widely adopted or impactful among the majority of diabetes patients. Of the 23 million patients diagnosed with diabetes in the U.S., 90% to 95% are type 2, with varying treatment needs. Many don’t have the financial means or coverage to access these technologies. So, although digital media and social networks offer opportunities to enhance communication between patients and their team of health care providers, they cannot replace the roles of the pharmacist, diabetes educator and physician relationships.
Rajora: Relevancy and immediacy are key expectations of consumers when it comes to digital media and social networks. A mobile device is used to view 75% of worldwide digital video, with 62% of consumers stating increased interest when they see a story on social media. People with diabetes look to social networks and groups for support and education. This high consumption can directly impact healthy habits such as reviewing injection technique and encouraging diabetes management. Social media influencers are important in driving healthy behaviors and encouraging people with diabetes to seek high-quality evidence-based information to help guide or support their diabetes management.
Kerley: Convenience is a key driver of patient behavior, and digital advances now enable patients to track blood glucose, blood pressure, weight, medication adherence and meals on a smartphone or computer. As more offerings focused on an enhanced patient experience are introduced, patients will ideally become more engaged. The ability for a patient to monitor their disease in an engaging, convenient way helps improve the patient experience and ideally leads to improved health outcomes.
Additionally, digital media and social networking create opportunities for patients to have an ongoing dialogue with their physicians while also tracking the progress they are making managing their diabetes. The result of these advances is more engaged patients that work with their health care team to simplify and personalize their therapies. Synchronizing patient information to a single patient-health-care-provider platform allows collaboration of care and access to comprehensive clinical information.
Houston: Pharmacists are becoming more prominent within a patient’s care team and play a critical role in improving health outcomes. Technology, like digital media and social networks, has aided in the pharmacist’s role and extended their reach in helping patients. It’s allowed the pharmacist’s presence to extend from within the pharmacy walls all the way to the hands of their patients, no matter where they are. Now, patients can be connected to their pharmacy and its resources anytime and anywhere.
Proper nutrition and regular exercise are critical components in diabetes management. Electronic wearables, like fitness trackers, can monitor a patient’s health progress and physical activity from caloric consumption to heart rates and even blood pressure. Wearables often include audible alarms and can potentially remind users to stay active or take medication. At the same time, they’re able to collect information. This data tracking can help patients stay on top of exercise goals and serve as a reference point for pharmacists when assessing their patients’ diabetes management and lifestyle goals.
Social networking platforms, pharmacy apps and digital platforms can also contribute to diabetes management. Pharmacists can use social media to deliver updates or reminders about diabetes management, healthy living and the signs of prediabetes, but the power of social media is the dialogue it creates; pharmacists can also use these platforms to respond to questions or share links to additional resources.
The Community Marketing offering from Good Neighbor Pharmacy enables pharmacist-owners to develop localized marketing strategies with a dedicated expert who will use data and analytics to help them connect more effectively with the people in their community. They can choose from a variety of standardized campaigns, including one for diabetes, and then customize them for their pharmacy to maximize awareness of their distinctive brand. Each awareness campaign features a different focus and professionally designed support materials, including social media content and outbound call scripts.
Patients are also using social media to find communities or support groups that offer motivation for self-management, promote healthy lifestyles and champion behavioral changes. In these forums, they can share encouragement or seek support if overwhelmed with their condition. Pharmacies have the opportunity to be a part of the conversation by being a trusted social media resource for patients.
CDR: How can pharmacies and in-store clinics offer nontraditional services — like screenings and recommendations for lifestyle and diet changes — to provide a holistic approach to diabetes care? And how can they take the same collaborative approach with physicians?
Brennan: Excessive weight and a sedentary lifestyle have been well documented as contributors to diabetes and prediabetes. A healthy diet of plant-based foods, lean animal proteins and foods low in saturated fat along with regular exercise can help control blood glucose, maintain a healthy weight and support appropriate blood pressure and cholesterol levels.
Because these types of lifestyle modifications can be challenging, CVS pharmacists provide personalized support and help direct patients to information and products that can aid in lifestyle management.
MinuteClinic nurse practitioners and physician assistants provide important health screenings and monitoring that help patients manage their diabetes and keep blood sugar in check in between doctor’s visits and over time. This care can help prevent the onset of diabetes-related complications.
CVS Health’s strategic relationships with electronic health record (EHR) providers, including Epic Systems, the most used EHR in the U.S., improves our health care providers’ access to clinical information and allows them to contribute to the patient’s care plan. This connection improves continuity of care and allows primary care providers to access information about the patient’s care in between their regular visits.
CVS Health’s more than 70 clinical collaborations with major health systems and providers also allow CVS pharmacists and our MinuteClinic health care professionals to support joint clinical programs. Facilitating access to prescription or other treatment information for shared patients with affiliate health care organizations ensures that all providers along the care continuum have a complete view of a patient’s prescription and medical records, facilitating informed decision making.
Pflieger: Pharmacies are uniquely challenged to balance the needs of patients with the needs of their business. Many pharmacies have tried incorporating diabetes education programs into their service offerings, only to abandon the programs months later because they could not find a way to offset costs and make these programs financially viable. Case studies performed as early as 2005 by the California Healthcare Foundation (CHF) provide insight as to why some programs fail, and best practices to help develop successful DSMD programs that serve the needs of patients while also meeting business objectives.
To start, CHF suggests modeling your program around the national standards for DSMD. Programs that meet these standards are recognized by the ADA, which can make them eligible for reimbursement through public payers, including federal and state programs such as Medicaid and Medicare. Private payers and self-insured employers may also provide reimbursement.
A holistic self-management program may also pay off in the long term. By covering topics from insulin injection and glucometer skills to nutrition and foot care, the patient and the pharmacy can benefit. Patient education leads to greater adherence and patient outcomes, and increased foot traffic drives O-T-C product sales. In grocery store pharmacies, nutritional guidance impacts food sales too.
Maximizing continuity of care requires collaboration among the entire care team. That means closing the loop between the physician’s office and the pharmacy. Doing so requires up-front diligence and persistence, but can be tremendously rewarding in terms of patient outcomes and can result in referrals that drive business growth. Development of thriving DSMD programs and collaborative practice agreements takes careful planning, time and patience. It’s a long-term investment that lays the groundwork for significant long-term pay-off.
Shah: We believe we can make a difference in patients’ lives by delivering accessible, high-quality, holistic care in collaboration with the broader health care team. Our newly launched statin program is one example of how we’re applying this approach to support our diabetes patients. The ADA recommends that diabetes patients over the age of 40 include a statin as part of their drug therapy to lower their risk for heart disease. Yet many patients with diabetes have never been offered a statin. As part of a new program at Walgreens, pharmacists can identify patients with diabetes who are not currently taking a statin and provide education and physician outreach around the heart health benefits of adding a statin to their medication regime.
Additionally, partnerships and collaboration will continue to be critical to delivering holistic care. Through our partnerships, we continue to transform our pharmacies into neighborhood health care destinations with many services for diabetes patients. In our pilot store in Deerfield, Ill., for example, our pharmacist can refer patients to on-site hearing and vision centers to test for diabetes-related complications.
Last year, Walgreens together with Onduo, Verily’s joint venture with Sanofi, launched a virtual diabetes solution to Walgreens employees and family members with type 2 diabetes through the Walgreens employee health plan. Onduo provides tools, coaching and remote access to specialty doctors. We continue to monitor the uptake and impact of this tool to evaluate future opportunities for this program.
Kerley: Pharmacists are prepared to be a part of each patient’s journey by providing education, screenings, immunizations and medication therapy management services such as adherence counseling and addressing gaps in care. Diabetes affects almost all aspects of a patient’s life, and management can be overwhelming. Collaborating with other health care providers such as dietitians or diabetes educators can help round out the comprehensive care that patients with diabetes need.
With the evolving health care landscape, a personalized, patient-centric approach to collaborative care among physicians and community pharmacists will continue to contribute to improving patient outcomes. Pharmacists extend care into the communities where the patients reside by leveraging local stores and offering a wider range of availability. Patients with chronic conditions like diabetes can benefit from having personalized and frequent contact with their very own health care team, including their pharmacist. Strategies can be individualized to include partnering with the physician to reduce the complexity of the prescription regimen, educational initiatives such as our Medicine Support Team, improved doctor-pharmacist-patient communication, and prescription reminder systems.
Rite Aid’s Medicine Support Team enables Rite Aid to reach patients who may not frequently be visiting our pharmacies to fill their medications. This type of outreach allows Rite Aid to remain connected to these patients and reinforce behaviors that lead to better disease state management and healthier lifestyles.
Rajora: We’re already seeing retailers take proactive approaches, based upon their business model, such as merchants offering fresh foods are determined to bring nutrition and pharmacy closer together in an effort to encourage health and wellness. We’re also seeing an increase in wellness days or rewards promotions for healthy habits. With Droplet, we aspire to support and advance pharmacist intervention with people with diabetes. Pharmacy programs we support include insulin starts, individualized consultations with callbacks, triaging patient’s injection experience and providing injection technique education, all of which have a direct impact on health outcomes and improving A1c levels.
Houston: Diabetes management is a constant process that requires a large amount of self-care, discipline and lifestyle adjustments. Healthy eating habits are one of the most important lifestyle components for diabetic patients. Maintaining a balanced diet can be overwhelming, but pharmacists can act as an essential resource for nutrition education and healthy eating recommendations. Pharmacists can address nutritional needs on an individual basis, taking into account a patient’s personal preferences and comfort level in adopting lifestyle changes. In addition, pharmacists can help patients frustrated with their dietary restrictions find solutions by providing new food alternatives and information on their nutritional benefits to managing blood glucose levels. As previously mentioned, there are also opportunities for pharmacists to collaborate with other nontraditional members of a care team, such as offering patients access to a nutrition counselor or even reviewing insurance policies to see if there are gyms or other healthy lifestyle benefits. It’s ultimately about reducing every barrier possible for patients, so they are as empowered as possible to manage their health.
Personalized counseling starts with fully understanding a patient’s health history and medical journey. Collaboration with health care providers and seamless data sharing across all channels of care are keys to a patient’s success.
CDR: To what extent should essential diabetes products be brought out from behind the counter and displayed in areas like end-caps? And how can products be presented in a more retail-friendly format — for example, with more appealing packaging?
Kerley: As mentioned previously, education is the foundation to diabetes care. According to the CDC, more than 30 million people in the United States have diabetes. Products must be positioned and expanded to help those with diabetes and their caregivers have easy access to the products that impact the management or assessment of their disease. Packaging should be presented to ensure patients understand the importance of using a product and how it will impact their care.
Diabetic products should continue to be positioned near the pharmacy to enable patients to be engaged with their pharmacist. Additionally, due to the high cost of some products, it may be necessary to keep items such as test strips behind the counter.
Rajora: Self-selection in the O-T-C area affords awareness to patients of products and services to support their diabetes management. By offering diabetes supplies in the visibility of the pharmacist, patients can seek counsel from the pharmacist, and also the pharmacist can proactively engage their patient in assessing medication management, diabetes control, and complication prevention. We’re seeing pharmacies using POP in the O-T-C area to connect O-T-C to B-T-C, promote access to the pharmacist, and inform patients of insurance coverage of their diabetes supplies. We’re also seeing testing of B-T-C products in the O-T-C section such as 30-count pen needle boxes offered to those patients with no or poor insurance coverage.
Houston: Signage and displays with targeted messaging that speak to diabetic patients can direct them to the pharmacy for further support. In addition to displays throughout the store, pharmacy staff can take a more proactive approach to engage with patients by walking them through the aisles and providing recommendations on products that advance their health goals. Good Neighbor Pharmacy business coaches and field support teams, including retail merchandising specialists, can help our members facilitate patient outreach by providing insights and identifying O-T-C products that appeal to the community’s patient population, like compression socks or therapeutic shoes.
Pflieger: As consumers continue to take a more active role in their health care decisions, pharmacies could better position diabetes care products by simply making them more accessible to their customers. At a minimum this means bringing diabetes essentials like lancing devices, lancets and meters out from behind the counter and placing them in the store aisles. To truly optimize positioning, pharmacies could create a focal point (like an end-cap) where diabetes care products are showcased and cross-promoted. In instances where drugs or devices must be carried behind the counter, pharmacies could consider marketing the product through shelf talkers or other signage that cross-promotes them, drives product awareness and encourages dialogue with pharmacy staff.
The shift from behind the counter presents an opportunity for manufacturers. Products sold behind a counter tend to present in a more clinical fashion, with a focus on text and sparing use of color and imagery. When consumers are allowed to interact with products directly, packaging design is influential in driving sales. Within a quick glance, packaging should explain what the product is and what purpose it serves. The face of the carton should “hook” the viewer to want to learn more, and side panels should further “sell” the product by highlighting key features and benefits.
Even behind the counter, packaging design can serve a purpose. When we redesigned Unifine packaging several years ago, we set out with two goals: (1) to improve ease and efficiency for pharmacists in identifying product type and specifications/sizes, and (2) to reinforce the purchase decision for the patient to establish loyalty and improve retention. The first goal was achieved through prominent color and text treatment to quickly delineate differences in needle lengths and gauges (others have since followed our lead). Our second goal was achieved by utilizing side panels to reinforce product attributes that speak to quality and differentiation.
Packaging is more than a container — it’s a powerful opportunity to engage with customers and drive incremental revenue. As an easy means of growing their market basket, pharmacies can look to partner with manufacturers who are already delivering retail-friendly packaging and programs.
Shah: Pharmacy team members can have a positive impact when they are involved in patient care, and diabetes patients often benefit from recommendations and counseling on O-T-C products such as syringes or blood glucose test strips. This is one reason these products are often positioned behind the pharmacy counter. At the same time, it’s important to strike a balance between care and convenience, so we regularly place diabetes products and merchandise on pharmacy-adjacent fixtures in conjunction with specific marketing campaigns to highlight diabetes products and services.
Customer insights are important to creating more simplified and appealing packaging. All of our owned-brand products, including those for diabetes patients, have either already undergone a refresh or are currently being repackaged based on customer insights. Updated packaging elements include new imaging and colors as well as better differentiation and product descriptions.
CDR: How can pharmacies shape their efforts to boost medication adherence to fit the singular needs of diabetes patients?
Brennan: Our Transform Diabetes Care program is so effective because we are able to marshal resources across our enterprise and provide a high level of local, personalized support and care via multiple touchpoints. The face-to-face counseling and education at our more than 9,800 pharmacy locations and more than 1,100 MinuteClinic locations occurs when patients are already thinking about how to get healthier.
The program uses advanced analytics to identify unique intervention opportunities for enrolled members. It then uses the company’s Health Engagement Engine to identify and prompt personalized counseling for enrolled members. They receive highly tailored support and coaching to help improve medication adherence, better track and control A1c levels and support healthy lifestyle behaviors. These services and resources are delivered at no extra cost, either in person, at CVS Pharmacy or by telephone. Members also receive comprehensive diabetes preventive monitoring visits (including A1c checks) at MinuteClinics with zero out-of-pocket cost.
Enrolled members receive a connected, cloud-based glucometer. The device provides real-time digital coaching and shares patients’ blood glucose levels with a team of experts, including certified diabetes educators. This technology enables the team to identify potential issues and intervene with one-on-one coaching. Certified diabetes educators provide one-on-one coaching personalized to the member’s needs, focusing on condition education, encouragement of healthy behaviors, improvement of condition management and goal setting.
Members also have access to digital tools within the CVS Pharmacy mobile app, such as medication refill reminders, to help reduce the complexity of daily disease management.
CVS Health’s corporate strategy to improve and simplify the patient journey is also reflected in a new health care concept store called HealthHUB. This innovative retail clinical engagement model, which debuted in three Houston-area CVS retail locations earlier this year, is designed to offer a broader range of health care services, including expanded capabilities in chronic disease care such as diabetes.
The HealthHUB features trusted health care counseling from pharmacists, nurse practitioners and dietitians and other allied health professionals; personalized care focused on “next-best clinical actions” to improve outcomes and drive cost-effective care; new health and wellness promoting product categories; and digital tools and on-demand health kiosks.
Shah: Adherence plays a significant role in improving outcomes and decreasing costs, particularly in patients with chronic conditions like diabetes. It’s important that pharmacists are counseling their diabetes patients on the importance of adherence to help them improve their overall health and well-being, as well as providing tools and services that make it easier to take their medicines as prescribed. One tool that Walgreens offers that’s proven to be very effective in improving adherence is our medication synchronization program, Walgreens Save a Trip Refills. This service has demonstrated gains of nearly 10% in adherence in patients with diabetes. These tools can go a long way in driving adherence to help patients look and feel their best.
Kerley: Pharmacists are in a unique position to support behavior change and improve adherence. Since pharmacological treatment is most often necessary for a person with diabetes to maintain glycemic control, it is very important for them to stay adherent to these regimens to ensure beneficial outcomes. Pharmacists are uniquely positioned to work with patients to identify barriers to medication adherence, offer solutions and ensure follow-up each time patients visit the pharmacy. Pharmacists have the ability to view patients’ refill history and be the primary source for counseling and education. Whether it is synchronizing maintenance medications, enrolling in prescription notifications, finding cost-saving alternatives or identifying other barriers to adherence, pharmacists are prepared to be part of each patient’s journey to health and wellness.
Nonadherent patients do not visit their pharmacy as often to fill their medications and interact with their pharmacists. To help support patients who may not regularly come in to the pharmacy Rite Aid is able to provide care services to our patients through Rite Aid’s Medicine Support Team, which comprises a team of Rite Aid pharmacists, nurses and specialists who provide live calls to patients in need of additional education and support to manage their medications and disease.
Houston: Adherence plays a crucial role in the success of medication therapies and positive patient outcomes. However, levels of adherence and barriers to proper medication usage vary from patient to patient. Pharmacists must understand each diabetic patient is unique and approach medication adherence individually.
Diabetic patients typically take multiple medications, which may have complicated drug regimens that increase medical costs along with the risk of nonadherence and long-term health complications. One way pharmacists can promote adherence is through medication synchronization, which makes it easier to assess patient behaviors and tailor proper interventions. AmerisourceBergen offers med sync program options that allow patients to schedule and pick up refills on multiple medicines during a single visit, resulting in fewer trips to the pharmacy and increased adherence. It also helps the pharmacy predict patient visits, which can simplify staff planning and inventory management.
AmerisourceBergen continues to look for ways to enhance its business-optimizing services and give pharmacists more time to focus on driving better patient outcomes. That’s why we support Community Pharmacy Enhanced Services Networks (CPESN), most recently as key sponsor of CPESN’s Luminary Conference in April 2019. CPESN represents a clinically integrated network of community pharmacies across the country that provide shared services, like medication-optimization activities, to ensure consistent care delivery and savings in patient care costs. Those services often focus on proper medication use and management, including med sync, comprehensive medication reviews, adherence monitoring and coaching, compliance packaging, home delivery and maintenance of patient medication records.
Improving the pharmacist-patient relationship is another means of enhancing compliance. Through transparent dialogue, consistent education and positive reinforcement, pharmacists can significantly impact a patient’s attitude and empower them to adhere to medications and other self-management care.
Rajora: Adherence to insulin therapy continues to be an obstacle for patients. With persistence to basal insulin after one year of 26% to 52%, and bolus insulin only 19% to 42%, it’s important to understand patient motivations and how products can improve injection experiences to improve adherence. Droplet delivers an improved and preferred injection experience to reduce barriers to injecting, such as anxiety and cost.
Each patient is motivated in unique ways — some are driven by information, some by cost savings, others by support or simplification. By tailoring diabetes management messages to each patient’s motivation, pharmacists can directly impact patient comprehension and health literacy to improve adherence.
ADA estimates that 40% of medical costs are due to increase in hospitalization rates and longer average length of stay. Adherence to diabetes medication was associated with statistically significant lower probability of hospitalization, emergency department visits and a shorter length of stay in the hospital. Adherent patients were also less likely to be diagnosed with an acute complication during the three-year post period.
We know that patients with diabetes see their pharmacist seven times more than their primary care physician. Also, a recent study proved that communicating with a pharmacist can directly improve adherence. As a result of pharmacist phone interviews with nonadherent patients with diabetes, 50% of patients were adherent at 90 days and 64.3% were adherent at 180 days, both statistically significant results.
With Droplet’s supportive educational program, we believe the pharmacist is the epicenter for patient care. As such, by offering tools for patients and pharmacists that can be personalized to each patient’s motivating factors, we aim to improve health literacy and, as a result, adherence.
Pflieger: The human element is the most complex part of the compliance equation, and this is why the pharmacy team has a pivotal, indispensable role to play. People stop or delay taking medication for different reasons. Some may be forgetful and require a gentle reminder, for others they may lack the education to understand the consequences — and for so many, cost bears an unsurmountable burden. This is why the pharmacy team is arguably the most influential gatekeeper in improving patient compliance. They are uniquely equipped with knowledge about the condition and treatments and can provide more economical alternatives (if available).
While leveraging data for patient adherence represents the biggest trend as of late, it cannot replace the relationship between a pharmacist and patient. Although automated messages may improve adherence for some, we must recognize that patient noncompliance exists for a multitude of reasons, and there are no algorithms or AI currently available to address all these factors. If you bombard patients (or pharmacists) with content that isn’t relevant to their concern, the message will be tuned out. The use of automated, data-driven messaging is best used to supplement or enhance one-on-one dialogue. The dialogue is needed to assess what underlying barriers are contributing to medication adherence.