Incentivizing Quality Diabetes Care at the Pharmacy

FEBRUARY 23, 2018


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; Tripp Logan, PharmD; Steven Peskin, MD, MBA; and Richard Wynn, MD, explore the potential for incentivizing high-quality diabetes care at the pharmacy level and offer advice for their colleagues.

Troy Trygstad, PharmD, MBA, PhD: So, pharmacy-to-pharmacy. Why don’t we do pharmacy-to-pharmacy? This is like internists not working with family doctors. “We don’t work with each other.” What’s the culture change there?

Dhiren Patel, PharmD: If that collaboration and exchange could happen, I think there’s a lot of value-add. Again, you know that in some of this postgraduate training that used to exist, this wasn’t the case. In community pharmacy, again, the majority think they’re going to a dispensing role. You now have a group who are those prescribers. They could teach some basic knowledge. For a lot of them, it’s not that they don’t want to do it, it’s just that they haven’t been trained in that manner, right?

When you get a prescription, you were just trained to make sure that it was the right drug based on how it was prescribed. That’s basically what you were trained to do. But as healthcare has evolved, so has that degree and so have those roles and responsibilities. Pharmacists are now prescribers. But again, there are different continuums of that. How do you close all of those knowledge gaps? If those that are on a continuum can help close that, then I think we all are going to be functioning at the top of our licenses.

Tripp Logan, PharmD: As pharmacists, even though they’re up to that challenge, if they’re given the opportunity to be reimbursed for that service, they do it 9 times out of 10. They have the ability to do it and are incentivized to do it. So, even the recognition to be brought into the circle, they need to be a part of that.

Troy Trygstad, PharmD, MBA, PhD: I would argue that 9 times out of 10, even if they got a prescription that said, “Hemoglobin A1C is 12.3%. They are newly diagnosed. The patient’s afraid of needles. Please follow up with the patient in 3 days,” you’d have a legion of folks out there saying, “This is professionally fulfilling. I want to help the patient, too.”

Tripp Logan, PharmD: I think you’re right.

Steven Peskin, MD, MBA: Yes. So, really enjoining it and working your colleagues into the journey. And then you say, “OK, you’re helping us with this particular population. If we get to our goals, then we’re going to share in a…”

Dhiren Patel, PharmD: Somewhat.

Steven Peskin, MD, MBA: Exactly.

Troy Trygstad, PharmD, MBA, PhD: We’ve meandered about in the discussion quite a bit. We’ve touched on a lot of uncertainties in the health care landscape and in diabetes care. But one thing is certain to me: If I had a son or a daughter or a parent or a wife with diabetes, I would like them to be cared by the 4 of you. So, we thank our panelists. It’s been a great discussion.

Before we conclude, I’d like to ask each of our panelists to share any additional thoughts on what we’ve just discussed, perhaps with one focus. All of you are esteemed colleagues. You’re looked up to by your colleagues, and you mentor a lot of folks. I’d like you to think about this in terms of diabetes, diabetes care, and the complexity of care that we’ve described. If you could offer one piece of advice, what would that advice be?

Dhiren Patel, PharmD: For me, it would be that for any given amount of time that you have in that visit—whether it’s 15 minutes, 30 minutes, or an hour—let the patient talk more. If you do that, your outcomes with that patient are going to be much better. If it’s a 1-way discussion, where you’ve talked for 35 minutes and they’ve said 2 words, you’re not going to get the outcome.

Troy Trygstad, PharmD, MBA, PhD: So, make a long-term investment, in your care delivery of that patient, by listening? Interesting.

Dhiren Patel, PharmD: That’s it.

Troy Trygstad, PharmD, MBA, PhD: Interesting.

Steven Peskin, MD, MBA: I’m going to go with simultaneity. As a clinician, whether she be a physician or he be a pharmacist, that individual, at that moment of truth, is what you’re all about. That said, you’re also continuing to look at, and evaluate and assess, how you’re doing on a population level. So, it’s simultaneity.

Troy Trygstad, PharmD, MBA, PhD: So, weaving in the encounter-based care with population management? Weaving in the tyranny, now, with the longitudinal view?

Steven Peskin, MD, MBA: Exactly.

Troy Trygstad, PharmD, MBA, PhD: That sounds easy.

Richard Wynn, MD: I’ve worked with students from Wake Forest and Chapel Hill and occasionally from Duke, as well. My first piece of advice would be to broaden your life experience. I was out of school for 5 years before I went to medical school. But it was time well spent. I was in a curriculum at Wake Forest where we were evaluated on patient skills—talking to patients, touching patients, interacting with patients, developing the ability to communicate what you feel toward the patient, and understanding what they need. Patients are all very different. They have different language skills, different assumptions about you, about health care, and about their health, their lives, and their values.

Troy Trygstad, PharmD, MBA, PhD: My impression is, the way you’re describing it, that experience and that appreciation for that need has helped you have a more fulfilling practice experience?

Richard Wynn, MD: Much more. The relationship with the patient is the thing that really turns me on about medicine. It’s the key to good patient care, I think.

Troy Trygstad, PharmD, MBA, PhD: Tripp, close us out strong.

Tripp Logan, PharmD: There are a few tips that we give to our residents, pharmacists, and students when they come in. One of them is, patient first. It’s not payer first. It’s not guidelines first. It’s always patient first. If you abide by that, then everything else works out. The payment piece works out. The metrics work out. Everything works out. You keep it patient-centric. Students get out of pharmacy school. They think that they should refer to the guidelines and that they’re going to save the world. But, you can’t always manage patient care based on those guidelines. So, I’ll end this with: patient first. Everything else always ends up working out after that.

Troy Trygstad, PharmD, MBA, PhD: Thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be useful and informative.
 


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; Tripp Logan, PharmD; Steven Peskin, MD, MBA; and Richard Wynn, MD, explore the potential for incentivizing high-quality diabetes care at the pharmacy level and offer advice for their colleagues.

Troy Trygstad, PharmD, MBA, PhD: So, pharmacy-to-pharmacy. Why don’t we do pharmacy-to-pharmacy? This is like internists not working with family doctors. “We don’t work with each other.” What’s the culture change there?

Dhiren Patel, PharmD: If that collaboration and exchange could happen, I think there’s a lot of value-add. Again, you know that in some of this postgraduate training that used to exist, this wasn’t the case. In community pharmacy, again, the majority think they’re going to a dispensing role. You now have a group who are those prescribers. They could teach some basic knowledge. For a lot of them, it’s not that they don’t want to do it, it’s just that they haven’t been trained in that manner, right?

When you get a prescription, you were just trained to make sure that it was the right drug based on how it was prescribed. That’s basically what you were trained to do. But as healthcare has evolved, so has that degree and so have those roles and responsibilities. Pharmacists are now prescribers. But again, there are different continuums of that. How do you close all of those knowledge gaps? If those that are on a continuum can help close that, then I think we all are going to be functioning at the top of our licenses.

Tripp Logan, PharmD: As pharmacists, even though they’re up to that challenge, if they’re given the opportunity to be reimbursed for that service, they do it 9 times out of 10. They have the ability to do it and are incentivized to do it. So, even the recognition to be brought into the circle, they need to be a part of that.

Troy Trygstad, PharmD, MBA, PhD: I would argue that 9 times out of 10, even if they got a prescription that said, “Hemoglobin A1C is 12.3%. They are newly diagnosed. The patient’s afraid of needles. Please follow up with the patient in 3 days,” you’d have a legion of folks out there saying, “This is professionally fulfilling. I want to help the patient, too.”

Tripp Logan, PharmD: I think you’re right.

Steven Peskin, MD, MBA: Yes. So, really enjoining it and working your colleagues into the journey. And then you say, “OK, you’re helping us with this particular population. If we get to our goals, then we’re going to share in a…”

Dhiren Patel, PharmD: Somewhat.

Steven Peskin, MD, MBA: Exactly.

Troy Trygstad, PharmD, MBA, PhD: We’ve meandered about in the discussion quite a bit. We’ve touched on a lot of uncertainties in the health care landscape and in diabetes care. But one thing is certain to me: If I had a son or a daughter or a parent or a wife with diabetes, I would like them to be cared by the 4 of you. So, we thank our panelists. It’s been a great discussion.

Before we conclude, I’d like to ask each of our panelists to share any additional thoughts on what we’ve just discussed, perhaps with one focus. All of you are esteemed colleagues. You’re looked up to by your colleagues, and you mentor a lot of folks. I’d like you to think about this in terms of diabetes, diabetes care, and the complexity of care that we’ve described. If you could offer one piece of advice, what would that advice be?

Dhiren Patel, PharmD: For me, it would be that for any given amount of time that you have in that visit—whether it’s 15 minutes, 30 minutes, or an hour—let the patient talk more. If you do that, your outcomes with that patient are going to be much better. If it’s a 1-way discussion, where you’ve talked for 35 minutes and they’ve said 2 words, you’re not going to get the outcome.

Troy Trygstad, PharmD, MBA, PhD: So, make a long-term investment, in your care delivery of that patient, by listening? Interesting.

Dhiren Patel, PharmD: That’s it.

Troy Trygstad, PharmD, MBA, PhD: Interesting.

Steven Peskin, MD, MBA: I’m going to go with simultaneity. As a clinician, whether she be a physician or he be a pharmacist, that individual, at that moment of truth, is what you’re all about. That said, you’re also continuing to look at, and evaluate and assess, how you’re doing on a population level. So, it’s simultaneity.

Troy Trygstad, PharmD, MBA, PhD: So, weaving in the encounter-based care with population management? Weaving in the tyranny, now, with the longitudinal view?

Steven Peskin, MD, MBA: Exactly.

Troy Trygstad, PharmD, MBA, PhD: That sounds easy.

Richard Wynn, MD: I’ve worked with students from Wake Forest and Chapel Hill and occasionally from Duke, as well. My first piece of advice would be to broaden your life experience. I was out of school for 5 years before I went to medical school. But it was time well spent. I was in a curriculum at Wake Forest where we were evaluated on patient skills—talking to patients, touching patients, interacting with patients, developing the ability to communicate what you feel toward the patient, and understanding what they need. Patients are all very different. They have different language skills, different assumptions about you, about health care, and about their health, their lives, and their values.

Troy Trygstad, PharmD, MBA, PhD: My impression is, the way you’re describing it, that experience and that appreciation for that need has helped you have a more fulfilling practice experience?

Richard Wynn, MD: Much more. The relationship with the patient is the thing that really turns me on about medicine. It’s the key to good patient care, I think.

Troy Trygstad, PharmD, MBA, PhD: Tripp, close us out strong.

Tripp Logan, PharmD: There are a few tips that we give to our residents, pharmacists, and students when they come in. One of them is, patient first. It’s not payer first. It’s not guidelines first. It’s always patient first. If you abide by that, then everything else works out. The payment piece works out. The metrics work out. Everything works out. You keep it patient-centric. Students get out of pharmacy school. They think that they should refer to the guidelines and that they’re going to save the world. But, you can’t always manage patient care based on those guidelines. So, I’ll end this with: patient first. Everything else always ends up working out after that.

Troy Trygstad, PharmD, MBA, PhD: Thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us. We hope you found this Peer Exchange® discussion to be useful and informative.
 
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