Five big ideas for chronic care management
As part of its annual Industry Issues Conference in December, Drug Store News assembled a first-class panel of retail pharmacy and supplier executives for an exclusive, in-depth discussion on emerging best practices for improving care among patients with chronic conditions.
Click here for the complete transcript.
For the 12th year, Hamacher Resource Group VP and co-owner Dave Wendland served as DSN’s special guest moderator. “As I was preparing for this year’s session, a group in the United Kingdom … had just published a report about dealing with chronic conditions and aging populations,” Wendland noted, setting the stage for the day’s discussion. “The first [was] 8-in-10 patients, according to U.K. physicians, are not taking their medications as prescribed; the second was that 92% of U.K. physicians said, ‘I wish community pharmacy would get more active and more engaged with our patients because we feel they play an important role;’ and the third was that [U.K. physicians believe that] the specialized knowledge pharmacists bring and their accessibility really completes the holistic care that these patients are seeking. The chain and independent pharmacy trade associations came together under one group called Pharmacy Voice to do that study.”
What follows here are five of the biggest ideas to come out of the panel.
1. Pharmacist: Moving from dispenser to adviser
If you had said to me when I graduated pharmacy school in 1976 that I would ever give an immunization to someone, I would have told you that you were out of your mind. Now it’s absolutely commonplace. In the state of Oregon, pharmacists [are] prescribing birth control pills in a collaborative agreement with the state.
… I think the real challenge is to figure out how it all works, and at the end of the day, … how we can become compensated for these [activities], and how we can use those new funding models to offset some of the losses on the other side of the equation. That’s the challenge. — Mike Mastromonica, assistant VP pharmacy services, Costco
About two years ago, we realized we had to get away from a dispensing model and get into a patient care-centered model. So we started working with … MTM …. What we found is that once we spread the MTM across the store — we made everybody responsible: technicians, pharmacy interns and the pharmacists — we started to identify immunizations that we could do. I think it was about … 88% of our CMRs that we do through MTM, we do 48% for free; it ends up we get an [immunization] out of it.
So that went further, … and we just kept adding what we had to work with. Currently, every CMR … in every … MTM … that we do ends up with med synchronization now. So we find out that after maybe about three touch points customers [are] engaged again, and all of a sudden [it goes from], ‘my pharmacist hasn’t really talked to me for a couple of years’ [to] ‘my pharmacist has an interest in my health care.’ — John DeJames, manager clinical programs and special projects, Giant Eagle
Health care has dynamically changed over the last three years. We have seen our model begin the shift from fee-for-service to value-based reimbursement. One of the catalysts has been the Medicare Part D Star Ratings Program. The impact it has had on access and payment in our most common patient population has changed how we approach our members and their corresponding actions.
Over the last three years, we’ve taken a very deliberate journey with them, and it first started with an awareness campaign. As an independent pharmacist you wear a lot of hats, which makes staying on [top] of what’s changing in the marketplace very tough. We shared with our members how clinical performance was being defined. Who’s measuring? Who are the stakeholders? How do you understand where you stand today? …
In year two we moved from awareness to adoption … such as how you use the MTM interventions … to have more deliberate conversations with patients; how to approach every conversation with a behavioral-based model for identifying patient gaps in care … .
Finally, we dug deeper to help shift the workflow model. If you go into most pharmacies and you ask them about their day, they respond with how many prescriptions they’ve filled. We’re trying to transition to, how many patients have you seen? How many conversations have you had? How many lives have you touched? — Tony Willoughby, chief pharmacist, Health Mart
2. Coordinated care, transitions in care — the pharmacist in the middle
Well Transitions is … an adherence-focused partnership between Walgreens pharmacists and a hospital system to help patients at discharge to make the transition back home. We target high-risk, chronically ill patients that we feel have a high readmission risk, and a Walgreens pharmacist [visits] them in their hospital room and talks to them about their disease, their medication, the importance of compliance and any other questions they may have.
Walgreens is becoming very patient-focused. We’re seeing very good response rates because they’re getting educated, they’re getting their questions answered and there’s that empathetic interaction at bedside. Also, hospitals and payers love it because it is improving healthcare outcomes and decreasing 30-day readmissions, which is the goal of the program. We [have] published white papers [on the program, and] it is working very well — 30-day unplanned readmissions are down 46% through the program. — Michael Wolf, DMM/director advanced care, Walgreens
[Another] area that we’ve learned is an obstacle — that was a surprise — is formulary management. We experienced one patient that was on a branded bladder control medication and a branded high blood-pressure medication; they went into the health system and those medications were not on the formulary. The hospital placed the patient on other, therapeutically equivalent products that were on the hospital formulary. Meanwhile, our pharmacy had already taken this particular patient through step therapy on these products previously, [and they] had not worked. The pharmacist explained the need to continue the original medications as the patient was experiencing bladder control issues and increased blood pressure … .
… In addition, there is always the potential risk that patients are discharged and start taking a new medication, plus a duplicate medication they already have at home.
So, there’s a lot of coordination needed, but this is definitely an area of opportunity. — Dan Miller, SVP regulatory affairs, Rite Aid
I think transitions in care is a huge opportunity for the entire market, and I include the wholesalers and the suppliers and everyone in that — [including] all the technology providers. … I mentioned [before] that I see our industry in general in a shift from a product-based focus into more of a service- and outcome-based focus. And … I don’t know that having an individual space on the shelf is the end game yet. I think it’s part of the game, but I think it’s a [part of a larger] opportunity. I mean that literally from the technology side in terms of how we reach the patients, keep them engaged and help educate them about their disease state through the Internet, through smartphone technology.
[It’s] also [a huge opportunity for] the wholesaler, making sure that some of the items that we’ve traditionally looked at as being very slow-moving in some scenarios are in the right place at the right time so that when there is a discharge and somebody needs a special type of bandage … that we, as retailers, have access to that fairly slow-moving, expensive product from the wholesaler, at the right time, at the right place. … — Leon Nevers, director pharmacy procurement and business development, H-E-B
3. Ending ‘Trial and Error’ medicine
Pharmacogenetics is … the study of not only how your body processes and excretes medications — your metabolism — but also your cells’ susceptibility to letting medication in, so it can do its job. Those two things really affect how your body is going to respond and process medications. With the current method of trial-and-error prescribing, prescribers send a patient home with a prescription with the best intentions of it working as desired for the patient. But they know patients process and respond to medications differently, unfortunately without pharmacogenetics, the prescriber is blind to how that specific patient will respond, thus the mindset is ‘Hey, this medication works 80% of the time; that’s pretty good odds.’
With pharmacogenetics the blindfold is taken off before the script is written, and the prescriber understands how that specific patient will respond and metabolize based on their genetic profile, enabling the prescriber to choose not only the right medication, but also the right dose that increases the likelihood of achieving the desired therapeutic effect, while also reducing the risk of unintended adverse drug reactions, which occur 2.3 million times a year in the United States and cause over 100,000 deaths a year. — Matthew Rutledge, president and co-founder, MD Labs
4. Behavioral modification: The new battleground
At Johnson & Johnson, we really view behavior modification as the new battlefield. We know that the 15 chronic conditions that account for 80% of healthcare costs are all tied back to eight human behaviors and risks: diet, exercise, sleep, stress, alcohol consumption, smoking … whether or not people are getting health screenings and also their standard of care. And all of those things can be adjusted, but … behavior change is really hard. I think all of us resist change. So we actually have a whole team of behavior scientists and experts at J&J. I don’t know how many of you have attended a Corporate Athlete program, but it’s focused on what’s important to you as an individual; what are you living for; what is your purpose, and aligning your life and your behaviors around that ultimate goal. So then, thinking about medication adherence or getting consumers to exercise more or eat better — all of these things have to be framed for that individual in that ultimate purpose.
We have a number of tools. We have digital health and coaching tools that we’ve developed. We have our Johnson & Johnson Official 7-Minute Workout, and we’re partnering with Walgreens on that for a Balance Rewards for Healthy Choices program … . We also have Care4Today, in which we’re partnering with Rite Aid to pilot some efforts around medication adherence using this mobile health manager. We’re trying to develop the tools that will enable not only consumers directly, but also enable the healthcare team in the store to help drive that behavior change … . — Alissa Hsu Lynch, VP sales strategy, operations and global capabilities, Johnson & Johnson Consumer
5. Patient engagement can change health care
One of the biggest challenges facing us today is continuing to remain relevant, and we’ve shared a lot on the panel about continuity of care and shifting from — in our case at BD — product-focus to being more patient-centric in providing innovation and solutions. In 2015, BD acquired Care Fusion and broadened its footprint to be [more involved] along that [pa-tient’s] journey of care at various touch points. And I think it’s a cultural change as well; it’s a cultural change to keep the patient at the center and then to provide communication both internally within our organization and stay externally connected with all of our industry partners so that we’re constantly providing education. Every year, 1.4 million people are diagnosed with diabetes; 10,000 people every day in the [United States] turn 65. And there’s one common requirement in our American population today, and that is to have knowledge at our fingertips, to be able to access from our phone or handheld device. We’re constantly … seeking new ways to nurture that engagement as partners and with our patients. — Rachelle Landry, director U.S. sales, BD Medical-Diabetes Care
Even though we execute transactions every day in our pharmacies — prescriptions, immunizations — it’s not a transactional relationship with our patients; it needs to be a patient-centered relationship. But that takes time, leveraging the different technology platforms — our wholesaler relationship, our enterprise systems and our pharmacists — with the right technology partners … . For instance, Shopko is working with Ateb to draw up medication synchronization; we are a PQA member, we use the dashboard from EQuIPP to identify opportunities to counsel our patients and drive adherence; we mine the MTMs … [but] that all takes time. So what we’re trying to do is drive operational efficiency and excellent standards in our stores to carve out those minutes and partial minutes, [and] put [it] back into patient-facing care.
A very simple acronym that we are now driving into our stores is, WELL, which stands for ‘Welcome’ in a genuine, authentic way; ‘Explain’ in a very clear way; ‘Look’ and ‘Listen.’ — Darren Singer, SVP retail health and wellness, Shopko Stores
As we looked at the change in U.S. health care, we felt like it was our responsibility as a partner to most of the manufacturers and all of the retailers in the room that we should help facilitate the new path to purchase around health care. Because, as consumers become more responsible and have to pay for their own health care, we felt like we needed to create an engagement tool that facilitated the ability for shoppers to do that because we typically provide promotion, and retail health care is actually converting from promotion to education and engagement. So we made an investment in a technology company … and we discovered that iBeacon could enable a new connection between patients and pharmacists where they are and where they need to receive education about their chronic conditions.
… Pharmatailing [creates] a bridge between the pharmacist and the patient, and between front-of-store items and therapeutic knowledge. Patients can get more information; they can self-advocate to the point where it can take pressure off the pharmacist. We don’t see the model changing on the volume side, so rather than continue to burden the pharmacist with more and more requests for consults, if we can deliver information on products that help manage symptoms, then we believe it will free up pharmacists so they can manage high-value patients. The Pharmatailing platform creates a secure connection to the pharmacy and cre ates a value queue for the pharmacist so they can know if a patient on their cell phone or their smartphone requests a consult; [they] can actually create a queue that the pharmacist can understand and can help deliver the health record with content … that they can self-curate and make recommendations for items in the front-of-store that help manage their symptoms. — Paul Murphy, senior director retail insights and innovations, Menasha
In addition to the treatments we have for diabetes, I think each of the panelists here has talked about the [patient’s] healthcare journey. And that healthcare journey really begins with awareness. At Novo Nordisk, we have been committed to empowering adults to take action for better health by learning the risk factors for diabetes. Our Ask.Screen.Know campaign encourages Americans to really learn their risk factors by taking the diabetes risk-factor assessments online. And as a result, they can work with their doctor or pharmacist, to … take those assessments and hopefully reduce that risk of diabetes moving forward. …
… We have programs, such as Cornerston-es4Care, where we teach patients all different aspects of their diabetes treatment, whether it’s healthy living or healthy eating, to the diabetes medication they’re on and every aspect of that. In addition, we work with our retail pharmacy partners to educate pharmacists on the importance of their role in the diabetes care continuum and educating patients on insulin delivery devices and diabetes medications, and we provide resources and training to them through our portal NovoMedLink.com. — Mike LaMotta, director trade operations, Novo Nordisk
CMS plan to boost MTM gains traction in Congress
“Better care, smarter spending, healthier people.”
Those were the goals set forth by the Centers for Medicare and Medicaid Services in September when it unveiled plans for a five-year federal experiment to gauge the effectiveness of expanded medication therapy management for Medicare patients. CMS’ Center for Medicare and Medicaid Innovation will launch the Part D Enhanced Medication Therapy Management pilot program in 11 states, beginning in January 2017, in a bid to spur Medicare Part D prescription drug plans in those states to boost their commitment to pharmacist-provided MTM services for their members.
(Click here to view the full report.)
The long-term goal, according to the agency, is “to test whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will engender enhancements in the MTM program, leading to improved therapeutic outcomes, while reducing net Medicare expenditures.”
The push to expand MTM services has gained traction at CMS — and within Congress — as its benefits as a tool for improving long-term patient outcomes and lowering health costs have become clear. Late last year, 44 members of the House, including 24 Republicans and 20 Democrats, sent a letter to Secretary of Health and Human Services Sylvia Burwell, urging the participation of retail pharmacists in the Enhanced MTM program, and the House Committee on Energy and Commerce Subcommittee on Health held a hearing on “Examining the Medicare Part D Medication Therapy Management Program.”
In their letter to Burwell, the house members noted, “we believe the proposed enhanced MTM model to be a positive step forward in improving the Part D MTM program. However, we also believe that without participation of retail community pharmacists, the testing of enhanced MTM models will fall short of achieving the maximum potential in terms of positive outcomes and impact on beneficiary health.”
Community pharmacy advocates laud the moves. “Studies conducted by entities including … CMS, the Congressional Budget Office and the Medicare Payment Advisory Committee show — among other results — that improved medication use leads to better health outcomes for patients, including reduced mortality; the reliance on fewer healthcare services, such as hospital readmissions and emergency room visits; and more cost-effective treatment of chronic conditions,” NACDS noted.
Kate Farms redesigns packaging to reflect rebranding
SANTA BARBARA, Calif. — A leader in plant-based, ready-to-drink meal replacements is debuting new branding and packaging to reflect its nutritional quality and taste.
Santa Barbara-based Kate Farms partnered with branding agency Hornall Anderson, whose clients include Starbucks and REI, to redesign the Kate Farms Komplete packaging to reflect its unique nutritional quality and great taste. Kate Farms Komplete is the world's first organic, non-GMO, vegan, gluten, dairy and soy-free RTD meal replacement shake.
"It was an honor to work with the folks at Kate Farms who are driven to make people's lives better by offering something exceptional in the market," said Jack Anderson, co-founder and chairman of Hornall Anderson. "They personally have experienced the impact that whole nutrition from nature can make on one's health. Our goal was to express their company motto 'All Good Things' in the refreshed brand."
In other news, Kate Farms also introduced seasoned industry veteran Michael Fougere as COO at Natural Products Expo West this week in Anaheim.
"Michael Fougere's track record of driving successful and strategic growth in the beverage industry will further expand Kate Farms Komplete's distribution without sacrificing our exceptional and unique nutritional quality," said Richard Laver, Kate Farms' founder.
Fougere was at the helm of Coca-Cola's entrance into New Age beverages, played a key role in the Coke-Nestlé Refreshment Company partnership, and was part of the Power Ade National launch team. Formerly VP of operations at Honest Tea, he has key former roles at Muscle Milk, POM Wonderful, Zico Coconut water and Plum Organics.