A Diabetes Intervention in Community Pharmacy Drives Value-Based Health Care
A collaboration with Blue Cross and Blue Shield of North Carolina focused on commercial populations has improved care and lowered costs in the state.
More than 50% of Americans are living with at least 1 chronic health condition. Spending around these conditions continues to grow, including upwards of $100 billion per year on excess hospitalization and $528 billion on the misuse, underuse, and overuse of medications per year. The solution, proposed Jon Easter, lies with pharmacists.
In a presentation at the 2024 National Association of Chain Drug Stores (NACDS) Total Store Expo, held August 17 to August 19, 2024 in Boston, Massachusetts,1 Easter—a professor of practice, the vice chair of practice advancement, PACE division, and associate faculty director at the University of North Carolina Center for the Business of Health—highlighted the crucial role of community pharmacists in a research project-turned-real–world program that has both improved patient outcomes and allowed pharmacists to be paid for their clinical work.
Reimbursement is crucial to ensure that pharmacists can continue delivering critical services. | Image credit: KatyFlaty - stock.adobe.com
“Affordability of health care is difficult now, and becoming more difficult,” said Easter. “It’s also impacting our country.” As national debt increases, the high health care spend—anticipated to make up nearly 20% of the US gross domestic product by 2030—“will continue to have an impact on our debt, as well as [on the United States] as a competitive country.”
READ MORE: Transforming Diabetes Interventions Into Sustainable Programs for Pharmacy
Much of that spend, Easter noted, goes to hospital care. By the time patients require that level of health care, they very well may have already experienced acute exacerbations, inadequate treatment, and other issues due to chronic diseases. “We’re not doing a very good job as a country on prevention and treating proactively,” Easter noted.
According to the most recent CDC data from 2021,2 an estimated 11.6% of the US population, or 38.4 million people, had diabetes, including 14.7% or 38.1 million US adults. Within this group, 8.7 million individuals were undiagnosed. In 2022, the total cost of diagnosed diabetes reached $412 billion in both direct and indirect medical costs in 2022. According to the American Diabetes Association, after adjustments were made for population age and sex differences, the “average medical expenditures among people with diagnosed diabetes were 2.6 times higher than what expenditures would be in the absence of diabetes.”3
Unfortunately for North Carolinians living in one of the 70 of 100 North Carolina counties classified as rural, health care access remains a significant challenge. “We have access issues,” Easter said. “We have worse outcomes when it comes to diabetes and economic conditions. We have health equity issues, social determinants that are more prevalent. As a state…health care is a huge challenge. But it’s also an incredible opportunity for pharmacy to solve a problem.”
It was with that backdrop that Easter and his colleagues, including the NACDS Foundation, who provided funding for the project, began working to address the high costs of diabetes care in the state.
The 3-step program included steps for patient identification, screening and pharmacist consultation to identify at-risk patients, and provider communication to refer at-risk patients and patients with diabetes with an HbA1c level greater than 8% for intervention. The intervention itself consisted of 6 sessions, focused on different aspects of disease management: general diabetes education, nutrition and exercise education, blood sugar education, heart disease, blood pressure, and cholesterol education, self-care education, and a health education session review. Sessions were conducted either over the phone or in person in a community pharmacy setting.
A total of 21 sites across 5 states participated in the research project, including small and large independent chains and large grocers in both rural and urban areas. This variety in project sites, Easter noted, was important to make sure that the intervention implementation “could be flexible based on which environment we were in, which gives us a better shot at repeating it sustainably and scaling it up at the end.”
Implementation itself was focused on 3 core areas: replication, sustainability, and success. “It’s starts with a useful intervention,” Easter said. “You have to have a defined intervention; what is it that you’re actually going to do?” Crucially, it must also be measurable: clinical metrics “[are] the currency by which our payers and providers and others want to see what pharmacy contributes to an overall project. What is the pharmacist contributing that is an addition to what a provider, case manager, [or other provider] can contribute?” These metrics—HbA1c, blood pressure control, the Patient Health Questionnaire-9—can be directly tied to the work that pharmacists are doing.
Overall, the outcomes of Easter’s project were positive: Throughout the research period, HbA1c reduced by a half-point, from 9.5% to 9%; pre- and post-intervention measures of disease state education knowledge improved in all 5 areas, as did patient quality of life. And although patient satisfaction wasn’t measured before the intervention, 100% of participants indicated at the conclusion of the program that they were satisfied with the education they had received.
Evaluation of pharmacist satisfaction, however, painted a slightly different picture. Intervention acceptability increased slightly and appropriateness remained flat, but when asked about feasibility and intent to sustain, interest in the intervention declined. Part of the feasibility issue, Easter explained, “was [that] we were still in the midst of coming out of COVID-19, and these pharmacists were reworking their workflows to incorporate this project. What they shared with us was, ‘We’re getting paid for our vaccinations; we’re not getting paid for this project.’”
That’s where Jasmine Perry, PharmD, CPHQ, and Blue Cross and Blue Shield of North Carolina come in. Perry is a senior clinical pharmacist at Blue Cross and Blue Shield of North Carolina, and has worked to develop More Than A Script, a partnership with North Carolina community pharmacies “to leverage free, enhanced services provided by pharmacists” as a means to increase access to high-quality health care for members of Blue Cross and Blue Shield North Carolina living with chronic health conditions.4
In June 2023, a pharmacy advisory group, including Perry, Easter, the UNC Eshelman School of Pharmacy, CPESN, the North Carolina Association of Pharmacists, and technology vendor DocStation among others, came together to figure out how to extrapolate the data from Easter’s research into a real-world intervention.
“With this program, we’re closing a couple of gaps,” Perry explained. “The first is the gap of pharmacist reimbursement; we’re now incentivizing pharmacists to do the clinical work that they had been doing previously at no cost. We’re also closing clinical gaps: Improvement in HbA1c, improvement in blood pressure, and alignment with [Pharmacy Quality Alliance] quality metrics. And beyond that, we’re leveraging the work that independent pharmacies have done and giving that information to our members.”
Through continued collaboration, Perry hopes to see continued growth of More Than A Script, expanding beyond independent pharmacy to other types of pharmacy organizations while advancing clinical practice. The team is also working to standardize the work they’re doing, to create an approach that can be utilized by other states, tweaked to fit their specific populations. “Through partnerships, through the work that’s been done…we’ve been able to develop this innovative, value-based care program in a space where we hadn’t seen a program done like this before,” Perry said.
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References
Easter J, Perry J. Leveraging diabetes care research to drive impact. Presented at: 2024 National Association of Chain Drug Stores Total Store Expo; August 17-19, 2024; Boston, MA.
National diabetes statistics report. CDC. May 15, 2024. Accessed August 19, 2024. https://www.cdc.gov/diabetes/php/data-research/index.html
Statistics about diabetes. American Diabetes Association. Updated November 2, 2023. Accessed August 19, 2024.
Trautman S. More Than a Script: Partnering with community pharmacists. Blue Cross and Blue Shield of North Carolina. Published July 23, 2024. Accessed August 19, 2024. https://www.bluecrossnc.com/blog/expert-takes/more-than-a-script
