Humanizing chronic care
MODERATOR’S NOTE: It should come as no surprise that 7-in-10 deaths in the United States today are caused by, or related to, a chronic condition. At least 45% of our current population suffers from a chronic condition. By 2025, 164 million Americans — nearly half of the population — will have at least one chronic condition.
America is increasingly being defined by complexity and multi-morbidity. According to an October study by Emory University’s Rollins School of Public Health in Atlanta, the co-occurrence of two or more chronic medical conditions is really becoming more predominant in our society. So when we think about chronic conditions, it may not be just one condition; it may be multiple co-morbidities, and it’s something that each one of the retailers and vendors who participated in this panel discussion in December is actively working to address today.
WENDLAND, HAMACHER RESOURCE GROUP: There has been a lot of change in health care.… How do you see… the future state of health care [evolving]?
MIKE WOLF, WALGREENS: The most important thing to focus on is the consumer.… It has to be very easy for her to navigate this ecosystem and… the solution really in effect has to be… easier than the current solutions [out there].
The next piece here is technology, and we’ve seen a great evolution on the technology side of things. When we started collecting data, we saw a lot of protection of that data by the people who collected it. It was their data… The new realization… is the openness of sharing, whether it’s EHRs or APIs — we’re finally realizing that the data really belongs to her; it’s the patient’s data. How they want to use it is up to them.
The other piece is data overload. So, as the healthcare system has evolved, there’s data everywhere — from hospital records, flu shot records, clinic records and pharmacy records. We even talked a little bit… about FitBits and the records that are coming in from devices. So the key to the new ecosystem will really be data refinement and actually using the data… to change behavior and ultimately improve outcomes.…
The [last piece] is security. With some of the financial data breaches we’ve seen, we’re… hearing a lot from her around the importance of security.
WENDLAND, HAMACHER RESOURCE GROUP:… How has retail pharmacy evolved,… and what do you see on the horizon?
MATTHEW RUTLEDGE, MD LABS: Well, a big question is who in this room has heard about pharmacogenomics this past year?… This technology effectively is under the umbrella of personalized medicine, which the president has mentioned in the past two State of the Union addresses. The new president coming in is saying it’s something he wants to support, so it’s something that’s going to affect all of us, not just as healthcare providers but as patients. And we can now look at your genetics and understand what medications you should avoid; what’s right for you, so the concept of introducing this into health care is now old. The concept of introducing this technology and empowering pharmacists to be the nuclei, to be the keepers of this information, that’s relatively new. And I’ve met with most of the major retailers in here and have talked about it; it is the future that we all see. It’s going to elevate and empower pharmacists to utilize their license to the best they can and drive a lot of the profit measure that we’re all looking to drive.
The question now is when and when are the infrastructures going to be built to enable it? When are patients going to show up and ask for it and demand it? When are insurance companies going to pay for it?
WENDLAND, HAMACHER RESOURCE GROUP: Len, [your company] has evolved as well through the years… Where [does] Johnson & Johnson see itself today beyond just a products company?
LEN GREER, JOHNSON & JOHNSON: At Johnson & Johnson, we really believe there are three key ingredients to making this work. One is behavior science. We talked a lot about medication adherence. Medication adherence is largely about behavior; there are a great number of influences. Why is it so hard to get people to take their medications as they should? Understanding those forces and putting them to work in solutions… is critical.
Another is starting with the patient.… You must take a patient-centered approach, apply design thinking and think through the whole journey of someone through a health condition or surgical episode, even beyond chronic conditions.
Third is analytics. Knowing … where to aim, how to prioritize, what’s working; using machine learning to improve.…
If you believe those things are key…, then you also have to believe that the retail environment is essential to making it work. It’s not an app; it’s not something delivered to your home.
WENDLAND, HAMACHER RESOURCE GROUP: Brendon, you and I were talking about the importance of the pharmacist intervention along the patient’s health care journey. What do you think is going to help enable the pharmacist to be most effective in that role?
BRENDON HILL, BD MEDICAL: Re-education can make a significant impact on both patient outcomes as well as quality of life. In partnering with healthcare professionals, we know that simply talking to a patient about how to properly inject their medication can significantly reduce A1C.
There are 29 million Americans with the disease. [In terms of] access for these patients,… there are about 5,500 endocrinologists compared with almost 300,000 pharmacists and 400,000 pharmacy techs. In addition, patients are in the pharmacy much more frequently, and pharmacists are always at or near … the most trusted professions. As such, pharmacists are ideally positioned to help the patient. At the same time, it’s critical that simple but effective interventions are developed that can be integrated into pharmacists’ busy workflow.
… I think the one thing we [should look at is] the evolving role of the pharmacy tech…to identify patients that would disproportionately benefit from the pharmacist’s intervention.
And then finally, we need to identify more progressive ways of enabling the engagement.
WENDLAND, HAMACHER RESOURCE GROUP: Kathryn,… nearly 16 billion injections worldwide involve reused or unsterilized syringes. Is that an issue… we [should] be concerned about that?
KATHRYN DUESMAN, RETRACTABLE TECHNOLOGIES: It is a big issue. When you look at the number of people that are self-injecting now — most of the research shows 8 [million] to 9 million people in the United States — which equates to about 3 billion injections every year in the United States. That’s a lot of sharps floating around, and some studies have shown… there’s a lot of inappropriately disposed of sharps.
Health care is moving out of what we used to call ‘traditional health care’. Now health care is in your home, and I — like probably most of the people here — travel all the time. So health care is taking place in hotel rooms; it’s taking place in restaurants; it’s taking place in sports or recreational facilities. These non-traditional settings are often where injectables are being administered.
The need for safe technology is so important. Retailers play a pivotal role in educating patients, not only about their medications… but on what technology to use and how to use it safely.
… Technology plays a huge role.… A truly nonreusable safety device may not be a silver bullet but it is a huge catalyst for behavior change, which is always hard. So the combination of the educational piece that pharmacists provide, along with technology that ends the lifecycle of used injection devices, makes us all safer.…
WENDLAND, HAMACHER RESOURCE GROUP: Tammy,… [how does] Rite Aid’s We Care program fit into chronic care management?
TAMMY ROYER, RITE AID: So at Rite Aid, we really encourage our pharmacists to view our patients holistically and make sure that we’re having meaningful conversations with our patients. And in order to do that, we need to provide them the opportunity to really be targeted in when they have those conversations and be mindful of the extra time that we request of our patients. So we’ve… created very defined targeted interventions utilizing technology and data — we don’t have a lack for that.… But we also train our pharmacists in motivational interviewing so that they have a tool to make those brief interactions meaningful conversations and really impact their patients.… We truly believe that a large part of what needs to happen is behavior modification, and without the opportunity to have motivational interviewing and some ways to really target the needed behavior side, the pharmacists are not going to be as successful in creating trust with that patient.
WENDLAND, HAMACHER RESOURCE GROUP: Becky,… before joining Costco, you [saw] some great examples of coordinated care.… Can you describe a little bit about that experience?
BECKY DANT, COSTCO: In my previous life, I came from a closed healthcare system where we were the insurance and the care provider, and that was a really nice environment to work in because everyone had the same goal: We wanted to keep that patient healthy and keep health costs down. And I think in the current environment in pharmacy, we don’t have as many independent pharmacists that have that close relationship with the providers in the area, so everyone is not necessarily on the same page… [on] the patient that they’re treating together. So,… can we find a way to recreate that closed environment in a retail environment? Can we find ways to collaborate with our local physicians to share the care of this patient? Can we come up with protocols to titrate somebody on their hypertensive medications or their A1C medications and get them to the goal? Can we help fill that primary care gap that we hear about every day and provide that care that’s missing to the patient?
WENDLAND, HAMACHER RESOURCE GROUP: Gregg, what role is technology playing at Shopko in the management of chronic conditions?
GREGG JONES, SHOPKO: 2016 for Shopko was the year of med synchronization. Our goal was to enroll at least 100,000 patients… A little feedback I heard recently from a pharmacist who most successfully [enrolled] almost 1,000 patients is that it has completely changed the workflow in his pharmacy. Really busy in the morning, he staffs for that accordingly, they fill all of the prescriptions for the patients in an orderly appointment-based solution; and in the afternoon, he’s able to spend time on immunizations, medication therapy management and other services.…
We have 270 pharmacies, half in very rural areas. … In the state of Wyoming, we have six pharmacies within 920 miles. We’re often the only health professional in those towns — very small towns — [and] the pharmacist is a trusted health professional. [We’ve added the] Higi health station [this year, which] can create an account for the patient to see their blood pressure, their BMI, their pulse, and then create that dialogue with the pharmacist.
We’re also piloting… a Tech-Check-Tech program.… Checking to see the NDC matches the label that matches the tablets in the container isn’t necessarily the best use of the pharmacist’s time today.
WENDLAND, HAMACHER RESOURCE GROUP: Leon, what do you see evolving from a monitoring device standpoint that is making an impact on the overall health and well being of a patient with chronic disease?
LEON NEVERS, H-E-B: … I went to the ECRM Diabetes event] this year. It just blew me away in terms of the advance in technology with blood-glucose monitoring, in particular, and the connection and the ability to produce alerts and really monitor — even on a consistent basis obviously through your device… [With a] Fit Bit… you can get everything on your wrist-watch; you can get everything on your iPhone; you can get everything on your Android.
A lot of the suppliers have technology that’s so far ahead of its time, and I think that’s good; I don’t mean that as a negative. But the issue that we face… is what are you going to do with that technology? And who’s going to own it, and when does it really make an impact? And when does it become… just an overload in the mind of the patient and the caregiver?
So I think that we’re standing on the edge of an interesting time in the world where technology is slightly ahead of our patient’s level of engagement. But I still believe that there’s a place in the future, especially with the next generation and the generation after that, who really grew up with this technology and understand it and can quickly prioritize it into their life.
WENDLAND, HAMACHER RESOURCE GROUP: Crystal,… what kinds of tools do [Health Mart pharmacists] need to make [their] jobs more effective and… engage… at the top of their license?
CRYSTAL LENNARTZ, HEALTH MART: From an independent pharmacy perspective, they’re really trying to meet the patient where they’re at, which in some cases is in the home. [Gregg] talked about medication synchronization, so aligning education and services with that monthly pickup with the patient, those are some ways that they’re executing it.
From a tools perspective, we’ve been helping … the independent pharmacist understand how health care is changing quality measures as well as performance and how they play an important role, not only to the patient but also to the providers in their area. And, as Becky mentioned, how can we help with some of those provider-pharmacist relationships at the local level? The second piece for us has been around engagement — engagement with tools so they can see how they’re performing, as well as in workflow tools to allow them to intervene with the patient when they have that patient in front of them.
And then…, we’re trying to build up a highperformance network of independent pharmacies so that we can look for those other partnerships on their behalf because it’s becoming increasingly difficult for them to do that one at a time.
WENDLAND, HAMACHER RESOURCE GROUP: Paul, give us some examples of what you’re seeing at retail that is better empowering that patient to make good decisions about… chronic condition management.
PAUL MURPHY, MENASHA: I’m not a pharmacist, a scientist or a doctor, so I have no idea how morbidity works, but the one thing that we can help solve are the three things that brick-and-mortar retailers struggle with the most, which is enabling patients to gain information and treat them as patients, engage them in the store more effectively, and where we come in is the execution part because we very much believe that you have to engage patients where they are.
So over the last two years, we’ve put a lot of thought and effort behind how do we support retailers and CPGs to stop promoting, because when you’re sick, you don’t want to be promoted to, you want to get education so you can self-advocate. And in today’s world, I’m sure with the changes politically, it’s going to continue to become more and more important for patients to self-advocate.
… We’re seeing a huge evolution in diabetes care centers that are adjacent to pharmacies, so it doesn’t put the patient in an awkward position. Because it’s much more personal to deal with your healthcare issues than it is to be a shopper; it’s a very big difference between the two things. We’re able to integrate technology so that the engagement piece is more meaningful to help self-advocacy.
Diabetes diagnoses spiking worldwide
Diabetes has become a worldwide epidemic. According to data recently published by the Brussels-based International Diabetes Federation, by 2040 more than 642 million people worldwide will suffer from diabetes, up from 415 million in 2015, the last year for which the organization has statistics. In North America, this figure is expected to jump from the current 30 million cases to around 41 million.
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In the United States, nearly 30 million have diagnosed cases of diabetes, and estimates show that as many as another 9 million more are unaware they have the condition. As a result, products and services to monitor and control diabetes have become a key part of community pharmacies’ home care offerings and are expected to become even more crucial going forward.
Diabetes advocates like the American Diabetes Association and IDF said the expected spike in the prevalence of diabetes around the globe will make easy access to diagnostic and testing equipment critical. And, they note, because an estimated 40% of adults with Type 2 diabetes do not know they have the condition, millions of people are putting themselves at risk of other health problems, including heart disease, stroke, blindness, and kidney failure.
All told, they said, diabetes accounts for nearly $250 billion in healthcare costs in the United States and $673 billion, or 12% of all healthcare spending, around the world.
While medical experts said the best option for patients, who may feel they have diabetes, is to go to a doctor, over-the-counter diabetes test kits can go a long way to helping people manage the condition. Recent advances in technology that have made these devices easier to use and more accurate have made home testing an ideal complement to physician care, they said. In addition to home testing and seeing a physician, a growing number of retail clinics are offering diabetes screenings. CVS Pharmacy’s MinuteClinic, Walgreens’ Healthcare Clinics and Kroger’s The Little Clinic are just three of the retail operators that offer screenings for diabetes in their walk-in health centers.
Executives said patients who rely on retail clinics for diabetes care are often disconnected from the healthcare system.
“Of those patients who come into the clinics, 56% don’t have a primary care doctor,” Little Clinic director of patient-centered strategies Cathleen McKnight noted during a presentation at The American Journal of Managed Care’s Patient-Centered Diabetes Care forum last spring. At that same event, CVS Health senior educator Kristene Diggins said a clinic in a retail setting allows nurse practitioners and pharmacists to work together to help counsel patients on drug therapy and drive medication compliance.
“Forty percent of chronic disease medications are never refilled,” Diggins said, noting that in many cases diabetes does not present any symptoms, and patients do not understand what their medications do.
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Home health care best practices
As a growing number of older Americans are making home healthcare increasingly attractive for drug store retailers, those in the industry say participating in this multifaceted market requires getting over some significant hurdles.
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“Over the past five to 10 years, the ‘path to purchase’ has changed from traditional destinations — home care providers — to a more diversified offering, including retail drug, mass, food, home improvement and e-commerce,” said James McGuiness, vice president of retail sales at Drive DeVilbiss Healthcare, which offers a wide range of durable medical equipment and other home care items.
As competition for shoppers’ home care dollars increases, drug store retailers will need to employ a strategy that will completely revamp the way they have traditionally approached this market, he said.
For example, McGuiness noted, retailers need to ensure they have what he calls “the right assortment,” optimizing the home care market’s multiple segments — mobility, bath safety, personal care and aids for daily living — to meet the basic needs to caregivers and patients.
When choosing which products to carry, retailers also need to consider the limitations that come with operating stores with limited floor space.
“DME can present a challenge as it is mostly large boxes that don’t typically turn as fast as other categories,” said Jeff Swain, VP of retail marketing at Compass Health Brands, which offers home care products under the Carex brand.
To overcome this space problem, Swain suggests that retailers feature smaller and faster-turning items in-store and combine that with a well-publicized online offering.
“If drug store retailers only offer limited product availability in-store and fail to direct the customer to their larger collection of online products, they risk having patrons be drawn to competitors with a larger product assortment,” he said.
However, those on the front lines warn that e-commerce is not for everyone.
“Competition is heavy online, and offering competitive pricing can be a challenge,” said David Svenson, director of home health care at Discount Drug Mart, which offers a wide range of home care products in its stores and is pondering whether to delve into e-commerce.
Focusing solely on brick-and-mortar, he said, allows retailers to offer personalized care, ensuring that patients get the right products — something an online store cannot do.
While such an approach means that a retailer cannot offer a complete mix of home care items, it also makes the business easier by limiting the need to deal with reimbursements from insurers.
“We advise pharmacy retailers to stick to the basics,” Compass’ Swain said. “This means starting with the cash business until they have grown as much as possible, and then expanding from there. Unless a pharmacy has a dedicated staff for reimbursements, we don’t recommend for retailers to play in that arena.”
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