Q&A: Optimizing pharmacy’s function
In August 2012, the American Association of Diabetes Educators highlighted recommendations and research confirming that more than one-third of the 25 million Americans with diabetes don’t take their insulin as prescribed, with 20% intentionally skipping doses and many admitting they inject it in the wrong place or at the wrong time or use the wrong technique, and only 30% of patients receive formal insulin education.
Collaborative Care recently had the opportunity to interview Jerry Meece, a pharmacist, certified diabetes educator and author of the AADE’s recommendations, about what pharmacists are — and should be — doing to address the problem.
Collaborative Care: What are the best practices you’ve seen in how retail pharmacists approach diabetes care?
Jerry Meece: I think that the best cases are when pharmacists approach their diabetes practices a lot like a physician office works. Think about it.
PCPs use their staff for everything up to — and sometimes including — patient interaction. Some examples:
Making appointments: It doesn’t seem natural at first, but if your staff agrees, we can “train” our diabetes patients to be more aware of our time. You can certainly give a quick answer every time it’s needed, but too often the timing isn’t right and we think we have to stop everything and answer every question to the end. Have patients come back if it becomes involved, so that you can give them your full attention.
Better utilization of staff: Delegate jobs that are repetitive to others. Find a good tech and assign them the title of “chief technician” or something similar, and put that person in charge of such jobs as checking blood glucose if you are doing those in-house, running a lipid panel, weighing, etc. I don’t need to take a patient’s blood-glucose reading — that takes up valuable time. What I do need is to get the results of that check from my tech, so that I can then talk about the results.
Provide a professional setting: Have a semi-private area where you can sit down, even for a few minutes and talk to your patient. It makes such a difference. It doesn’t have to be fancy, but it has to be out of the way where you can listen and talk.
CC: What have some been doing wrong or insufficiently, and what can they do differently?
Meece: I think we can go back to the last statements for good practices and just reverse them.
As pharmacists we’ve long thought that we had to grab every phone, answer every question and do every job ourselves. As a result, we skip over a lot of the essentials in good patient care or don’t do the best job we can with our patients. So make a plan with staff that a patient will most often not come directly up to you and interrupt your work — it would never happen in any other professional office. By having someone intercept the patient to find out what is needed, time is better allocated. What often is the case is that possibly the patient didn’t need to see the pharmacist at all, or not until other issues were resolved, such as billing, cost of a medication, a meter not working, etc. It’s great to interact with the patient who comes in, but just do it at the right time for the best utilization of your time. Delegate.
We don’t get the buy-in from our staff like we should when we start a project such as creating a diabetes care or education center. We need to explain to them why we’re taking on this new program, what it will mean to them — better organization, possible bonuses and raises, stability, etc. — and what it will mean to the pharmacy — more business, income, a higher profile in the community. And that yes, you might be taking more time with certain patients as the program grows, so help out and explain to waiting customers what is going on. Everyone sees the value. If the staff does not buy in and treat it like an important professional aspect of the pharmacy, then it just does not fly.
Poor signage: Too often as pharmacies we try to nudge our way into something, and we wonder why it does not go. Every aspect of the pharmacy, from when the diabetes patient first walks in, should say professionalism and show the practice is a go-to pharmacy for their diabetes needs. Signage and handouts are a good example. Wholesales and pharma companies are great resources for what you need to make a good first impression. These are the areas you certainly don’t want to cut corners on. When a diabetes patient walks in to the store, they should be able to instantly locate a well-stocked up-to-date diabetes center. Carry the most up-to-date supplies — think new shorter needles for syringes and insulin pens — and not only will you as a pharmacist seem knowledgeable about the advantages, but having that chief tech knowledgeable as well is critical to showing people that you are in this business to stay.
CC: What do you see as the future of diabetes care at the retail pharmacy level?
Meece: The future is bright if we take advantage of what we already have in place. For pharmacists to not only survive, but also thrive, they have to move from retail pharmacy to a clinical community pharmacy setting, where the things we just talked about take place. It does not take a lot of money, but it does take focus and effort. Dispensing of information and knowledge in the form of diabetes education will be an important adjunct to dispensing meds.
Pharmacies need to become accredited, or “recognized,” as diabetes self-management training programs by either the American Diabetes Association or the American Association of Diabetes Educators so that they can get reimbursed for working with patients by Medicare and insurance companies. Many pharmacies are doing that just now by attending workshops that help them down this path.
Pharmacists can go a long way toward becoming an integral part of the diabetes team by playing to their strengths, examples of which are increasing adherence with medications, making physicians and patients aware of new technologies that are available and being able to step in as a problem-solver when the opportunity arises.
For example, we know that many diabetes patients skip their insulin doses or put off starting insulin for various reasons. A primary reason could be because needles make them anxious or because they try to avoid the pain of injection.
Adding an insulin pen to their therapy could help with this issue because of the discreteness and because being able to use a new technology like a 4-mm needle that allows single-handed injection and reaches the correct fat tissue for insulin injection is less intimidating and much more comfortable. But many patients are still using the longer 12-mm needles that not only have no advantage, but also require two-handed pinch-up and may even cause hypoglycemia to occur if the injection goes too deep and enters a muscle. We now know that 4-mm insulin pen needles and 6-mm syringe needles work for almost every patient who comes into our pharmacy. Educating patients and physicians about options available to them and backing it up with the latest research is an important part of our work, and this will become even more of a focus as pharmacies offer more opportunities for one-on-one patient consultations. The AADE has pointed that that only 30% of diabetes patients receive formal insulin education, and so education provided by pharmacists might help to close this gap.
Pharmacies are perfectly positioned to take on a lot of the load that is needed to treat the current epidemic of diabetes that is expected to get bigger in the coming years. We are accessible, can utilize staff to multitask and have the facility already in place that will complement our dispensing programs.
Insurers turn to retail, urgent care clinics to keep members out of emergency rooms
Shifting patients away from hospital emergency rooms and into retail-based and urgent care walk-in clinics can significantly lower healthcare costs, improve access to care and reduce the impact of such chronic diseases as diabetes and hyperlipidemia, two health benefits experts asserted in a recent online presentation.
In a webinar titled “How Retail and Urgent Care Clinics Can Be a Win-Win for Health Plans and Their Members,” the two experts — Susan Menendez, director of strategic provider relationships for Blue Cross and Blue Shield of North Carolina, and Tom Charland, CEO of health consulting firm Merchant Medicine — laid out a strong case for walk-in clinics as a powerful tool to reduce expensive visits by health plan members to emergency rooms and provide an accessible professional care alternative for millions of Americans living in areas facing a shortage of primary care physicians. Such clinics also can extend a local health system’s reach within a community as part of an accountable care organization, provide a medical home for some patients and make patients more responsible for their own health, they said.
Retail and urgent care clinics, Charland said, are “expanding the scope of services” they offer walk-in patients, providing “an alternative to primary care.” And health plan payers, he said, are taking notice. Increasingly, they’re looking to clinics to play a role in improving patient access to health services, lowering costs for routine and preventive care and serving as ad hoc medical homes for patients “where there’s an extreme shortage of primary care physicians,” he noted.
Given “the hours, the locations, the consistency of service,” Charland said, “I personally believe that walk-in medicine has done more for patient-centric behavior and patient satisfaction — and the focus on patients as customers — than anything since doctors made house calls.” Charland attributed the rise in retail and urgent care clinics to “medical providers acting like merchants, and acting like they want patients to come back and have a positive experience.
“It’s no longer built around the provider, or providers’ hours or locations,” he added. “It’s built around the patient.”
To this point, however, retail and urgent care clinics have followed different growth tracks. Although urgent care has seen steady gains over the past decade, the retail clinic market experienced “a leveling off in 2008 and 2009, when people were trying to figure out what was going on, and it’s only just recently that Minute Clinic, under CVS’ guidance, has decided to start opening new clinics,” Charland said.
Nationally, the use of retail clinics saw healthy gains from 2006 to 2009, according to a study from Rand Corp., from 1.48 million total patient visits to roughly 6 million. “But those figures still pale in comparison to ER and regular physician visits,” noted Atlantic Information Services in a report. “An estimated 117 million ER visits and 577 million visits to doctors’ offices are made each year.”
Nevertheless, said Charland, “These clinics are here to stay” as health plans, payers and patients incorporate them into the nexus of care. He also predicted “a lot more cooperation” from doctors as “the changing economic model is starting to change their behavior from being able to do as many procedures as you can, to getting that procedure in the spot where it can be done with the highest quality at the lowest cost. And if that does take over, I think we’ll see walk-in clinics start to be integrated into more of these ACOs and clinically integrated networks.”
Although most retail clinics “have yet to break even,” Charland added, the profit picture is improving as operators have learned to “smooth out some of the seasonality” of their business by broadening their menu of services and as patient traffic has picked up. “Now that these clinics are at break-even, we’re going to start to see some of the operators open more clinics,” he predicted.
Investing in urgent care solutions
The need among health plan payers to curb the rising costs of emergency room care for non-emergency health problems has become increasingly urgent, Menendez said. “We have seen our costs for ER services continue to increase over the last several years,” said the Blue Cross Blue Shield strategist. “We know that thousands of patients visit crowded emergency rooms for non-life-threatening conditions that we believe can be treated very cost-effectively and efficiently in urgent care centers. And we know that a visit to an ER can cost up to 10 times more than visiting an urgent care center…[at] nearly $1,500,” she said.
In response, BCBS purchased a stake last year in FastMed Urgent Care, the largest urgent care clinic provider in North Carolina. “In those pockets of the state where we have primary-care shortages, this type of model is very attractive to us,” said Menendez. “We know that primary care shortages in North Carolina will only worsen in 2014 and beyond. So we’re looking now at solutions around primary care, as well as having options other than the local hospital for these members.”
Menendez said the Blues launched a project in 2010 “to look at these ER costs and services, and really try to understand what is driving members going to ERs. What are the behaviors and the most common diagnoses that members go to ERs for?”
ER-use rates are higher in rural areas of the state, she said, at rates of “around 200 per 1,000 members, and that’s incredibly high,” versus about 140 visits per 1,000 members living in urban areas. In addition, BCBS knows that “women of childbearing years and young males have the highest ER rates. We’re trying to drill down into that and understand why.”
The Blues tracks a list of 15 to 20 diagnoses that drive the most nonemergency ER visits, including headaches, back pain, sore throats, urinary tract infections and upper respiratory infections.
One big reason for the high ER utilization rates: the shortage of primary care physicians, coupled with the fact that many residents in North Carolina don’t have a regular doctor to visit for treatment and counseling, even for common conditions. And again, BSBC members in rural areas — including “some pockets of the state where the only option for receiving nonemergent care is the local hospital,” Menendez said — are the least likely to have a primary care physician. “That’s very concerning to us, given some of the health crisis issues we have today.”
Thus, the executive said, BCBS is targeting some distinct population groups to lower their rate of ER visits and steer them into retail clinics, urgent care centers and other alternative, lower-cost healthcare sites. Among the target groups are:
Members in poor access areas;
Those with no primary care doctor;
Members with a moderate health situation that has not occurred previously; and
Those with persistent health conditions.
In a bid to shift its members away from high-ticket visits to the emergency room for nonemergency health issues, the company also adopted a tiered approach to out-of-pocket patient costs. To that end, BCBS began raising its patient co-payments for routine care at the ER.
The boost in co-payments — $100 in 2001 to $150 beginning in 2004 — did result in reductions in ER utilization among members, but what’s needed is a broader, more comprehensive approach to providing health services that encourages patients to make better use of other care options like retail clinics and urgent care centers. To that end, BCBS also invested in FastMed, a network of 26 urgent care centers across North Carolina. The insurer also began a pilot project with several employer groups to help educate their workers on alternative care sites like clinics.
“We believe that providing access to additional clinics in North Carolina can help us achieve that reduction in ER visits,” Menendez said.
Indeed, shifting patients away from the ER and into retail or urgent care clinics in the state would yield significant cost savings. “An overall 5% shift in ER to urgent care utilization would result in about a 74 cent-per-member-per-month savings, and that translates into almost $8 million annually,” she said.
BCBS of North Carolina and FastMed now co-sponsor community events like health fairs, wellness and prevention events, and blood-pressure checks. “We did a huge voucher mailing in mid-November to members who live close to a FastMed location, waiving co-payments for those members. And we continue to work together to identify short- and long-term strategies around strategically placing new clinics across the state where we have high ER costs and inappropriate utilization.
“We know that if we can get these members who don’t have primary care physicians into that [clinic-based] primary care space, and get them linked into preventive and wellness programs, we can do incredible things to head off such chronic diseases as diabetes, hypertension and cardiovascular problems — all the things that we are so struggling with here in North Carolina due to environmental factors,” Menendez added.
Addressing drug-related nutritional deficiencies
As more Americans are prescribed medicines to alleviate their chronic metabolic conditions, more Americans are exposed to common drug-induced nutrient depletions, noted pharmacist and supplement expert James LaValle, CEO of Integrative Health Resources.
Drugs can inhibit the absorption of a nutrient, LaValle noted. “It can change its metabolism, its synthesis, the way it’s transported, the way it’s excreted,” he said. Another compounding factor is that each patient is unique, he added. “The problem is issues [with prescribed medicines] don’t pop up in a linear fashion because people are complex.”
Another problem contributing to nutrient depletion is the adoption of new drug therapies as patients age because they never adequately addressed the underlying cause of their chronic condition through better health choices, meaning diet and exercise. Lavalle uses the example of “Patient Joe” to illustrate the impact the layering on of additional drug therapies can have on the patient’s total health over the course of adulthood. “Patient Joe” might start out on a statin, a proton-pump inhibitor and ace inhibitor at age 35, but if he doesn’t lose weight, quit smoking and exercise more, then he may pick up prescriptions for metformin for diabetes and/or an NSAID for osteoarthritis in five to 10 years, or a calcium channel blocker for blood pressure and/or a beta blocker for arrhythmia in another five years beyond that.
So given the complexity of the patient, the objective at any health consultation touchpoint is to evaluate what medicines a particular person is taking and the nutrients that are depleted by them. “The reality is this — people are put on medications every day,” LaValle said, and unless they present with something like a physically-evident allergic reaction “we assume that when somebody goes on a medication that it’s OK. That they’re doing fine on that medication. No big adverse event happened,” he said.
It’s important to know which medicines deplete which nutrients.
“A statin depletes Co Q-10, but it also depletes [vitamin] C, selenium and omega-3 fatty acids,” he said. “Proton-pump inhibitors we know deplete vitamin D and calcium; it’s a warning [on the drug facts label],” LaValle said. PPIs cause bone loss. “Two-in-10 cases of osteoporosis are now men. Now we’re putting men in their 30s on drugs like PPIs, and we’re keeping them on them for decades,” he noted. “Are we screening our men at 45 years when they’ve been on PPI therapy for 10 years?”
Many prescription medicines include information regarding increased risk for other disease states, such as diabetes or cardiovascular disease, LaValle said. “What they don’t tell you is ‘why?’ A lot of it is nutrient-related.”
Nutrient depletion can exacerbate underlying conditions. For example, men on statins are two times more likely to have low testosterone, LaValle noted. “Low testosterone is now a big risk factor for men as it relates to their cardiovascular risk,” he said. “So if I take their cholesterol down, but I take their testosterone [down too], that’s a big problem.”
To make testosterone, men need magnesium and zinc. To help control high blood pressure — another factor that can lead to increased cardiovascular risk — physicians may prescribe a thiazide, which depletes magnesium and zinc. So prescriptions for a statin and thiazide can lead to increased cardiovascular risk due to underlying nutrient depletions, LaValle noted.
Patients on these nutrient-depleted therapies may need to supplement with the depleted nutrients — it may not be good enough to improve diet and increase exercise, LaValle suggested. “The issue is we’re not realizing that all of the trace minerals and nutrients that people aren’t getting in their diet are what are regulating our genomic expression,” he said. “It’s not just eating right and exercise. It’s about understanding these complications when people are on medications, understanding that they’re individuals and they need individual evaluation,” LaValle noted.
“I’m passionate about the patients [with whom] I come in contact,” LaValle added. “I want to make a difference in their life and I’m going to do anything I can to convince them … into feeling a little bit better,” he said. “If you have patients who are in a polypharmacy event with multiple nutrients that have been depleted over a long period of time” then take care of them, LaValle said.