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HEALTH

Diabetic connection: Chain pharmacies reach out to their communities

BY Nora Caley

Diabetes is a complex disease not only for researchers and healthcare providers, but for pharmacists and others in the retail realm. Industry experts said offering services for consumers with diabetes goes beyond dispensing medications, and if done well, can drive traffic and increase store revenues.

The pool of patients with diabetes is increasing. According to the Centers for Disease Control and Prevention in its National Diabetes Statistics Report for 2017, 30.3 million people — or 9.4% of the U.S. population — have diabetes. Of those, the CDC said 23.1 million people have been diagnosed, and 7.2 million people — or 23.8% of people with diabetes — are undiagnosed.

Also, according to the CDC’s Diabetes 2017 Report Card, the rate of new cases of adults being diagnosed with diabetes has decreased each year since 2008, but overall, the total number of adults with diagnosed diabetes continues to go up. The CDC attributed the increase to people living longer with the disease, “because of improvements in self-management practices and healthcare services.”

These services, the CDC noted, include the more than 4,100 diabetes self-management education and support, or DSMES, programs offered across the United States. In 2016, about 1.1 million people with diabetes participated in DSMES programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators.

Jodi Lavin-Tompkins, director of accreditation for the AADE, works with pharmacies to get accredited to provide self-management education and training. “Usually, they are interested because they have customers coming to the store that have diabetes to fill prescriptions,” she said. “If they can get them some education while they’re in the store, it’s more convenient. This is just another service they are adding for their customers.”

She added that in the past year, she has seen a huge uptick in the number of pharmacies AADE is accrediting. “They are looking for other sources of revenue,” she said, referring to Medicare reimbursements for the education services. “They are also interested in community health.”

In addition to Medicare reimbursements, the CDC’s Division of Diabetes Translation provides grants to state and local health departments to support programs and activities related to improving health outcomes for people with diabetes. The current round of funding is State Public Health Funding 1305. “Every time they fund states, we get calls,” Lavin-Tompkins said.

To become accredited, pharmacies must complete an application process and meet 10 national standards. The curriculum is centered around what the organization calls the AADE7 Self-Care Behaviors, which are healthy eating, being active, monitoring, taking medication, problem solving, reducing risks and healthy coping. Once accredited, the pharmacies offer classes for groups of people, often only about 5-to-10 attendees at a time. Some stores do not have enough room to offer the classes, so they might borrow space from a local library or community center.

Offering the classes also provides another benefit — helping the pharmacy develop relationships with the providers in their area. “They have to get a referral for the service from the provider,” Lavin-Tompkins said. “They are interacting with the providers when they are doing the service, and they also have to communicate back to the referring provider on what education they provided for the participants, and what outcome each one achieved.”

Billing Medicare
Retailers can get financial benefits from offering these educational sessions in the form of Medicare billing. “There are a couple of revenue streams that pharmacies are taking more advantage of than they have over the last several years,” said Brahim Zabeli, vice president of sales at Tampa, Fla.-based Smart Meter, which makes the iGlucose diabetes care solution. “One is medication therapy management, or MTM, and the other is remote patient monitoring, or RPM.”

Pharmacies can offer MTM to consumers, who are on several medications, to make sure they are adhering to their medication plans, and can bill Medicare for the services. The pharmacists have to undergo training and follow certain guidelines.

RPM is a newer service that allows patients to send such healthcare information as a glucose measurement to a healthcare professional in real time. “That’s a pretty powerful tool,” Zabeli said. “Prior to RPM, what the patient would end up doing was taking blood glucose tests multiple times a day, and on a quarterly basis they might see their doctor. The doctor would review the tests, and the information might be three months old.”

In November 2017, CMS updated its payment policies, including separate payment for CPT code 99091, which is collection and interpretation of physiological data, such as glucose monitoring, that is digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, requiring a minimum of 30 minutes of time. The change went into effect on Jan. 1. “To some degree, pharmacies haven’t taken full advantage,” Zabeli said. “But it’s so new, it’s not entirely surprising.”

For its part, Smart Meter is using the Internet of Things to make it easier for people with diabetes to test their glucose and send the information to healthcare providers. The iGlucose blood glucose meter sends the information wirelessly to the person’s Circle of Care, which is the designated healthcare provider that reviews the information. There also is the iGlucose virtual coach that sends texts and reminders to the user, and a web portal that automatically updates the information so the person doesn’t have to keep a logbook of test results.

“The patient is no longer in isolation,” Zabeli said. “It should help patient adherence, and it should help patient engagement. When all is said and done, patient outcomes would be better than it otherwise would have been.”

The better patient outcomes would come from the fact that the technology would help patients make fewer mistakes in administering their own insulin. According to a 2013 study published in the Clinical Toxicology medical journal, of 642 cases of unintentional insulin errors over a 22-month period, 97.5% occurred in the home. According to a 2016 study published in Clinical Diabetes: A Publication of the American Diabetes Association, even patients who had been diagnosed 15 years ago still made mistakes in administering insulin, and the majority of people in the study believed they were administering their insulin correctly, even though they suffered “wide glycemic excursions.”

Other services
Whether the patient education at the pharmacy takes the form of several sessions of a diabetes class, or a more informal interaction with the pharmacist, pharmacies can benefit from these relationships.

Diabetes care also can help retailers compete with online shopping, according to Casey Pflieger, director of North American marketing at Owen Mumford, the U.K.-based medical device manufacturer with U.S. operations in Marietta, Ga. “Thinking like an e-tailer means mining data, while also finding ways to make the shopping experience easier, faster and more convenient.”

The retailer can use behavioral shopping data in-store to cross sell through coupons or on shelf. Pharmacies can create such focal points as endcaps to showcase diabetes care products.

Also, Pflieger said, such diabetes essentials as lancing devices, lancets and meters can be brought out from behind the counter and made more accessible to consumers. “When drugs or devices must be kept behind the counter, pharmacies may consider marketing the products through shelf talkers or other signage that cross promotes, drives product awareness and encourages dialogue with pharmacy staff.”

This dialog with pharmacy staff is essential. “Diabetes is a complex condition, and pharmacists can have a profound impact on patients, which often translates into higher sales and improved retention,” Pflieger said.

Shoppers who have diabetes also end up buying not just insulin, but also such other products as low glycemic index foods, nutritional supplements, socks, insoles and other items. “There are cross-marketing opportunities, because their baskets are typically larger than other customers walking into the store,” Doubleday said. “There is the potential for pharmacy to market to them.”

Even if the store does not offer a formal educational series, pharmacies can engage with customers with diabetes in other ways. Often, it involves training on how to use products. The newest product from Dexcom is the Dexcom G6, a CGM system that sends glucose readings to a compatible smart device and receiver every five minutes with no fingersticks. The system consists of a sensor beneath the skin, a transmitter that sends data wirelessly to a device and a display device with a small screen. It also can share the data with the user’s loved ones, so that they can be alerted if the person has, for example, a hypoglycemic reading while they are sleeping.

More insurance companies are now covering CGMs, Doubleday said, noting that retailers can benefit from the technology by training consumers on how to use the device. “As more and more retailers become aware of this product, this is becoming the standard of care for anyone using insulin,” he said. “They are going to have to be knowledgeable, so there is an opportunity for the pharmacy to be on the leading edge on this transition of therapy.”

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