Evolving Community Pharmacy Role in Diabetes Care

FEBRUARY 22, 2018


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; Tripp Logan, PharmD; and Dhiren Patel, PharmD, offer their perspectives on the evolving role of the community pharmacist in improving diabetes care.

Troy Trygstad, PharmD, MBA, PhD: That’s an interesting fascinating way of thinking about care. But we’re inside the bubble. So, if I asked the next 100 persons on the street, “What role does your community pharmacy have on your health care team,” they might shrug their shoulders. How do we not only expect more, but change expectations not only in the provider community, not only in the physician community and planning community, but even within the pharmacist community? How is it that we’re working with community pharmacies? If they’re going to Tripp’s pharmacy 35 times a year—our data tell us that patients who are being intensively care managed are going to Tripp’s pharmacy 35 times a year—why don’t we have this sort of cultural awakening to, “Here’s this great asset, out there”? Maybe not all 10 pharmacies are ready to do it, but if Tripp’s is ready to do it, why are you not working with Tripp more closely? Why are we not expanding this type of a model?

Richard Wynn, MD: Because insurance payers make you go to the pharmacy that they choose.

Troy Trygstad, PharmD, MBA, PhD: OK, that’s one aspect of it.

Richard Wynn, MD: One of the issues is that pharmacies are not all the same.

Troy Trygstad, PharmD, MBA, PhD: Sure, which is not necessarily a bad thing.

Richard Wynn, MD: No, they have their place.

Troy Trygstad, PharmD, MBA, PhD: Some are services based and some are convenience based. Different patients have different needs, right?

Richard Wynn, MD: But making this sort of discussion penetrate into the larger pharmacy chains and having more interaction and communication…

Steven Peskin, MD, MBA: We have this notion that the medical neighborhood is very poignant for us. The medical neighborhood is around primary care, health home, cardiologists, urologists, and psychiatrists. I really like this notion of thinking about the community pharmacy or pharmacy being a part of that. We have not typically thought in those terms, but you bring up an interesting construct.

Troy Trygstad, PharmD, MBA, PhD: So, there’s 65,000-odd pharmacies out there. Heretofore, the way of thinking about them in a larger policy payer and provider sphere is, if not all 65,000 pharmacies can do it, then none of them should do it versus why wouldn’t you have a scenario? You make referrals to folks that you work with all day long, right?

Richard Wynn, MD: Yes.

Troy Trygstad, PharmD, MBA, PhD: So, if not all pharmacies are the same, and they’re an underleveraged asset, you touched on something that’s really important. You’re a small business owner, Tripp, correct?

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: You believe that you take care of patients well? You work with other providers in the community well? Ostensibly, you have better clinical and humanistic and total cost of care outcomes, if we were able to do that analysis. How is it that you’re paid?

Tripp Logan, PharmD: Transactionally, on the prescriptions, for 99-point, some odd percent.

Troy Trygstad, PharmD, MBA, PhD: Fundamentally, this is really no different than any of the other challenges we’ve had with fee-for-service. We’ve got a misalignment with what we’re trying to accomplish with this particular provider type and the way we incentivize activities and payment. To me, being trained in population health management and health economics, 35 times a year is exactly what I need for my care managers and my primary care doctors, and so on and so forth. So, really quickly, how do we get there? You’re a pharmacist that works in an ambulatory care clinic. Do you have go-to pharmacies that you could work with? What wouldn’t you work with pharmacies on, that are going to help you with your metrics?

Dhiren Patel, PharmD: I think what you’re describing is very ideal. I wish it was, like you said, that easy to do. Even pharmacists are not all created equal. Some are trained differently. And so, I think just the general awareness is a consideration. You guys have a very good integrated model. You kind of understand the value-add of having community pharmacists and a clinical pharmacist. But, again, how do you get that information disseminated? You have a good relationship. You’re aware of those services, but someone else might not be. It’s almost to the point where you have hip and knee replacements. You know certain surgeons have better outcomes, and you get that data quickly. Some employers are like, “Oh, this is what we’re going to be using for ‘XYZ.’” You could almost have a center of excellence and say, “For Tripp’s pharmacy, this is where you kind of do that.” I don’t know how you logistically do it. But, again, there’s got to be some payment model or incentive model or some billing model for him to be able to do that. At the end of the day, he also has his bills to pay. He can’t just have an extra pharmacist available because he wants to do the right thing and counsel more patients.

Troy Trygstad, PharmD, MBA, PhD: My apologies, Steven, but because you’re representing a payer point of view, you get the second radical hypothetical of the day. What’s so radical about having either all of the pharmacies or some subset of pharmacies being measured on hemoglobin A1C? Even the ability to produce the hemoglobin A1C seems to be indicative that you’ve got a relationship with providers in which you are able to interact with the patient. Isn’t that a quality indicator in and of itself? Wouldn’t it be irresponsible to say, “I’m working with a patient with diabetes, and I’m helping manage that patient,” but you’ve got no visibility of the clinical markers or your patient goals or health concerns, and so on and so forth. So, why haven’t we introduced that, from a payer community perspective? Then tie that to health home, medical neighborhood, pay-for-performance?

Steven Peskin, MD, MBA: I would say that you’re not going far enough, Troy. The hemoglobin A1C is—again, I think we all agree—an imperfect measure. That said, you do raise a very legitimate challenge that I’m going to take back to the ranch and talk about. We have had great results with having clinical pharmacists involved in our health system transformation and delivery system transformation. We have not yet enjoined our community pharmacies. And so, I’ll take on that challenge.

Troy Trygstad, PharmD, MBA, PhD: Alright.

 


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; Tripp Logan, PharmD; and Dhiren Patel, PharmD, offer their perspectives on the evolving role of the community pharmacist in improving diabetes care.

Troy Trygstad, PharmD, MBA, PhD: That’s an interesting fascinating way of thinking about care. But we’re inside the bubble. So, if I asked the next 100 persons on the street, “What role does your community pharmacy have on your health care team,” they might shrug their shoulders. How do we not only expect more, but change expectations not only in the provider community, not only in the physician community and planning community, but even within the pharmacist community? How is it that we’re working with community pharmacies? If they’re going to Tripp’s pharmacy 35 times a year—our data tell us that patients who are being intensively care managed are going to Tripp’s pharmacy 35 times a year—why don’t we have this sort of cultural awakening to, “Here’s this great asset, out there”? Maybe not all 10 pharmacies are ready to do it, but if Tripp’s is ready to do it, why are you not working with Tripp more closely? Why are we not expanding this type of a model?

Richard Wynn, MD: Because insurance payers make you go to the pharmacy that they choose.

Troy Trygstad, PharmD, MBA, PhD: OK, that’s one aspect of it.

Richard Wynn, MD: One of the issues is that pharmacies are not all the same.

Troy Trygstad, PharmD, MBA, PhD: Sure, which is not necessarily a bad thing.

Richard Wynn, MD: No, they have their place.

Troy Trygstad, PharmD, MBA, PhD: Some are services based and some are convenience based. Different patients have different needs, right?

Richard Wynn, MD: But making this sort of discussion penetrate into the larger pharmacy chains and having more interaction and communication…

Steven Peskin, MD, MBA: We have this notion that the medical neighborhood is very poignant for us. The medical neighborhood is around primary care, health home, cardiologists, urologists, and psychiatrists. I really like this notion of thinking about the community pharmacy or pharmacy being a part of that. We have not typically thought in those terms, but you bring up an interesting construct.

Troy Trygstad, PharmD, MBA, PhD: So, there’s 65,000-odd pharmacies out there. Heretofore, the way of thinking about them in a larger policy payer and provider sphere is, if not all 65,000 pharmacies can do it, then none of them should do it versus why wouldn’t you have a scenario? You make referrals to folks that you work with all day long, right?

Richard Wynn, MD: Yes.

Troy Trygstad, PharmD, MBA, PhD: So, if not all pharmacies are the same, and they’re an underleveraged asset, you touched on something that’s really important. You’re a small business owner, Tripp, correct?

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: You believe that you take care of patients well? You work with other providers in the community well? Ostensibly, you have better clinical and humanistic and total cost of care outcomes, if we were able to do that analysis. How is it that you’re paid?

Tripp Logan, PharmD: Transactionally, on the prescriptions, for 99-point, some odd percent.

Troy Trygstad, PharmD, MBA, PhD: Fundamentally, this is really no different than any of the other challenges we’ve had with fee-for-service. We’ve got a misalignment with what we’re trying to accomplish with this particular provider type and the way we incentivize activities and payment. To me, being trained in population health management and health economics, 35 times a year is exactly what I need for my care managers and my primary care doctors, and so on and so forth. So, really quickly, how do we get there? You’re a pharmacist that works in an ambulatory care clinic. Do you have go-to pharmacies that you could work with? What wouldn’t you work with pharmacies on, that are going to help you with your metrics?

Dhiren Patel, PharmD: I think what you’re describing is very ideal. I wish it was, like you said, that easy to do. Even pharmacists are not all created equal. Some are trained differently. And so, I think just the general awareness is a consideration. You guys have a very good integrated model. You kind of understand the value-add of having community pharmacists and a clinical pharmacist. But, again, how do you get that information disseminated? You have a good relationship. You’re aware of those services, but someone else might not be. It’s almost to the point where you have hip and knee replacements. You know certain surgeons have better outcomes, and you get that data quickly. Some employers are like, “Oh, this is what we’re going to be using for ‘XYZ.’” You could almost have a center of excellence and say, “For Tripp’s pharmacy, this is where you kind of do that.” I don’t know how you logistically do it. But, again, there’s got to be some payment model or incentive model or some billing model for him to be able to do that. At the end of the day, he also has his bills to pay. He can’t just have an extra pharmacist available because he wants to do the right thing and counsel more patients.

Troy Trygstad, PharmD, MBA, PhD: My apologies, Steven, but because you’re representing a payer point of view, you get the second radical hypothetical of the day. What’s so radical about having either all of the pharmacies or some subset of pharmacies being measured on hemoglobin A1C? Even the ability to produce the hemoglobin A1C seems to be indicative that you’ve got a relationship with providers in which you are able to interact with the patient. Isn’t that a quality indicator in and of itself? Wouldn’t it be irresponsible to say, “I’m working with a patient with diabetes, and I’m helping manage that patient,” but you’ve got no visibility of the clinical markers or your patient goals or health concerns, and so on and so forth. So, why haven’t we introduced that, from a payer community perspective? Then tie that to health home, medical neighborhood, pay-for-performance?

Steven Peskin, MD, MBA: I would say that you’re not going far enough, Troy. The hemoglobin A1C is—again, I think we all agree—an imperfect measure. That said, you do raise a very legitimate challenge that I’m going to take back to the ranch and talk about. We have had great results with having clinical pharmacists involved in our health system transformation and delivery system transformation. We have not yet enjoined our community pharmacies. And so, I’ll take on that challenge.

Troy Trygstad, PharmD, MBA, PhD: Alright.

 
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