Pharmacist Coaches Lower Copayments, Improve Outcomes, and Reduce Costs for Employees With Diabetes

Service Delivery Innovation Profile

Pharmacist Coaches Lower Copayments, Improve Outcomes, and Reduce Costs for Employees With Diabetes

Snapshot

Summary

As part of the Diabetes Ten City Challenge, employers reduced or waived copayments related to diabetes-related drugs and supplies and assigned a pharmacist coach to meet periodically with employees who have diabetes to assess and strengthen their skills related to self-management of the disease. A pre- and post-implementation analysis found that the program reduced total health care costs and led to statistically significant improvements in key outcomes measures, including mean levels of blood glucose, cholesterol, and blood pressure. The program also increased the provision of services known to improve the health of those with diabetes, including influenza vaccinations and eye and foot examinations.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of total health care costs and key outcomes and process measures, including blood glucose, cholesterol, and blood pressure levels, and the provision of influenza vaccinations and eye and foot examinations.

Developing Organizations

American Pharmacists Association Foundation; HealthMapRx, LLC

The American Pharmacists Association Foundation is located in Washington, DC. HealthMapRx, LLC is no longer an active organization.

Use By Other Organizations

Approximately 80 employers have adopted the basic elements of this program (i.e., pharmacist coaching and reduced or waived copayments for diabetes-related drugs and supplies through the HealthMapRx program). HealthMapRx had also developed a similar, employer-based program targeted at cardiovascular disease, which provides pharmacist coaches and reduced/waived copayments for lipid-lowering agents and blood pressure medications.

Date First Implemented

2006

Patient enrollment for the Diabetes Ten City Challenge began in January 2006 and concluded in 2008. Employers may now enroll in similar programs through regional pharmacy networks.

Problem Addressed

Diabetes is a common, costly disease that can lead to serious complications and death. Although proactive patient self-management that includes monitoring of blood glucose, regular eye and foot examinations, proper diet and exercise, and medication adherence can prevent many common comorbidities, very few individuals with diabetes follow these guidelines. Pharmacists represent an underutilized but potentially effective resource to assist patients in improving self-management.

  • A common, costly condition: Diabetes affects approximately 23.6 million people in the United States, representing 7.8 percent of the population. Although incidence increases with age, many of those with diabetes still work—in fact, 10.8 percent of those age 40 to 59 have the disease. The seventh leading cause of death in the United States in 2006, diabetes increases the risk of heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations, dental disease, and pregnancy-related complications.1 The total costs of diabetes are estimated to be $174 billion, consisting of $116 billion in direct medical costs and $58 billion in indirect costs, including disability, missed work (roughly 15 million days are lost each year due to diabetes-related absenteeism2 ), and premature mortality. This latter figure does not include the costs of “presenteeism” (when workers are at work but not fully productive), which likely exceed the costs of absenteeism.3
  • Unrealized benefits of patient self-management: Patients with diabetes who successfully manage their glucose, blood pressure, and lipid levels can significantly reduce the risk of complications and comorbidities; in addition, regular eye and foot examinations and proactive screening and treatment of kidney disease can also significantly reduce diabetes-related problems.1 In spite of this, very few individuals with diabetes do a good job in managing the disease. In fact, a recent study estimates that less than 2 percent of adults with diabetes follow American Diabetes Association recommendations for self-management, including blood glucose monitoring, diet and physical activity, and medication adherence.4
  • Largely untapped potential of pharmacists to help: Studies have shown that pharmacists can help those with diabetes better manage their condition, including controlling blood glucose levels and ensuring that appropriate services (e.g., eye and foot examinations) are provided,5 yet relatively few individuals with diabetes have access to such pharmacists in the community.

Description of the Innovative Activity

As part of the Diabetes Ten City Challenge, self-insured employers in 10 cities reduced or waived copayments for diabetes-related drugs and supplies and assigned a pharmacist coach to work on a regular basis with employees who have diabetes to improve their self-management skills. Key elements of the program are described below:

  • Marketing and enrollment: Participating employers marketed the program to qualified employees and enrolled those interested in participating. Participating employers included private companies in a range of industries as well as local government agencies in cities such as Chicago, Honolulu, Milwaukee, Los Angeles, Pittsburgh, and Charleston, SC. All were self-insured. During the Ten City Challenge, staff at the American Pharmacists Association Foundation assisted with this step, providing forms and templates. Originally, HealthMapRx, LLC, a partnership of the foundation and Mirixa Corporation, provides a “turnkey” program to assist employers interested in continuing with the protocol used in the Ten City Challenge. (See the Context section for more information on these organizations.) Today, employers may enroll in similar programs through regional pharmacy networks.
  • Reduced or waived copayments: Participating employers either reduced or completely waived copayments for diabetes-related drugs and supplies. Many employers also reduced or waived copayments on angiotensin-converting enzyme inhibitors, and a few did the same for lipid-lowering agents and blood pressure medications. A handful of employers—often those whose copayments were already low—also waived copayments for primary care physician visits, laboratory tests, and eye examinations. Some employers with wellness programs provided “wellness points” (part of an incentive program tied to wellness) to employees who participate. Employers typically worked with their pharmacy benefits management vendor and/or third-party administer to operationalize these changes.
  • Pharmacist-led coaching on self-management: A network of pharmacists with expertise in diabetes-related care was set up in each area where participating employers were located. The local network assigned a pharmacist to each participant, and the pharmacist contacted the participant to set up the initial meeting, with subsequent meetings taking place at least quarterly. Meetings were held in locations convenient to participants, including retail pharmacies (both independent and chain stores), ambulatory clinics, and at the worksite. Participating employers typically paid these pharmacists on a per-visit or per-hour basis. More details on the sessions are provided below:
    • Initial meeting to assess self-management skills: At the initial session (which typically lasted 1 hour), the pharmacist took a medical history, conducted a brief physical assessment (e.g., height, weight, blood pressure), inquired about current providers and medications (including any problems with these medications), and asked about any diabetes-related goals that had been set with these providers. The pharmacist also began to assess the individual's baseline knowledge with respect to diabetes and his or her ability to self-manage the condition. To assist with this task, the pharmacist used the Patient Self-Management Credential for Diabetes, an externally validated, proprietary tool developed by the American Pharmacists Association Foundation, and offered as part of the HealthMapRx program.
    • Subsequent meetings to develop skills: Subsequent face-to-face meetings occurred as deemed necessary by the pharmacist, with a minimum of one meeting every 3 months. The typical participant received coaching four to seven times a year. During these sessions, the pharmacist coach worked with the employee to improve those self-management skills found to be weak during the initial assessment. Once the participant became proficient in diabetes self-management (according to the credential-scoring guidelines), the pharmacist awarded a credential to the individual. Some employers also recognized this accomplishment by awarding a certificate to the individual.
    • Performance meetings: Although the program analysis was originally intended to evaluate outcomes over a 1-year period, many employees continued to meet with the pharmacist coach even after having become proficient in self-management. During these meetings, the pharmacist ensured continued compliance with medications, provider visits, glucose monitoring, eye and foot examinations, flu shots, dental visits, and the like.
    • Referrals to outside specialists: Pharmacists referred participants to a dietitian or other specialist if needed. The pharmacist was usually familiar with the benefit plans of participating employers, and thus knew what services were available to the participant as part of his or her health insurance coverage.
    • Communication with regular care providers: The pharmacist communicated with the participant's regular health care provider(s) on an as-needed basis, most often after every meeting, highlighting key activities, goals, referrals, and recommendations that came out of the session.

Context of the Innovation

Located in Washington, DC, the American Pharmacists Association Foundation works to create a new medication use system in which patients, pharmacists, physicians, and other health care professionals collaborate to improve cost effectiveness and quality. To that end, the foundation conducts research demonstration projects and offers programs to pharmacists that advance their professional training. HealthMapRx LLC was a joint venture of the American Pharmacists Association Foundation and Mirixa Corporation, a private company established by the National Community Pharmacists Association. HealthMapRx programs provided employers the opportunity to implement the successful demonstration projects of the foundation.

The Diabetes Ten City Challenge represents the continued evolution of a program developed over the last decade by the foundation and other organizations. The model was originally tested as part of the Asheville Project, where the city of Asheville, NC, decided to reduce or eliminate copayments and provide pharmacist coaches to patients with diabetes. After this initiative achieved positive results (including lower costs and improved outcomes), the same model was pilot tested with employers several years ago to see if the results achieved in Asheville could be replicated. When they were, questions remained as to the scalability of the model, which led to the decision to test it in 10 diverse communities across the nation as part of the Ten City Challenge. Given the program's potential to improve quality and reduce costs (and the fact that many employers were calling to express interest in the program), the foundation decided that dedicated resources should be developed to promote its spread, which led to the decision to create HealthMapRx in February 2009 as an entity to take on this role. Today, employers may enroll in similar programs through regional pharmacy networks.

Results

Pre- and post-implementation comparisons for 573 participants across the 10 cities show that the combination of reduced or waived copayments and pharmacist-led coaching led to greater adherence to recommended care processes, improved key outcomes measures related to diabetes (including control of blood glucose, cholesterol, and blood pressure) and lowered overall health care costs. 3

  • Better adherence to recommended processes: Participants were more likely to receive recommended services, including influenza vaccinations (rates increased from 32 percent before the program to 65 percent afterward), eye examinations (57 to 81 percent), and foot examinations (34 to 74 percent).
  • Improved outcomes: Participants experienced a statistically significant decline in mean levels of blood glucose (from 7.5 to 7.1 percent), low-density lipoprotein (98 to 94 mg/dL), and systolic blood pressure (133 to 130 mm Hg).
  • Lower costs: Total annual health care costs per participant were $1,079 lower than projected, representing a 7.9 percent decline. Pharmacy expenses increased by 31.9 percent versus projections for employers. (Employee out-of-pocket drug costs fell by 37.9 percent because of the reduced/waived copayments.) These increased drug costs were, however, outweighed by savings in other areas, yielding a net reduction in overall costs.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of total health care costs and key outcomes and process measures, including blood glucose, cholesterol, and blood pressure levels, and the provision of influenza vaccinations and eye and foot examinations.

Planning and Development Process

Key elements in the planning and development process included the following:

  • Recruiting employers: Self-insured employers were recruited through a variety of means, including conducting information sessions and, in some cases, working through local business coalitions on health. Participants had to agree to bear the costs of waived copayments and to pay the pharmacists for their time.
  • Supporting implementation: Foundation staff helped employers implement the program, providing consulting advice and technical assistance.
  • Forming pharmacist networks: Typically, one organization or individual took the lead in forming the pharmacist network within an area, such as a representative of the state pharmacy association, a pharmaceutical consulting firm, or a university pharmacy program.
  • Training pharmacists: Because pharmacist experience with diabetes varies, participating pharmacists generally had to complete a continuing education or certification program in diabetes care. Options included an online course or inperson classes, although in most cases a “live” component was used to ensure the pharmacist was qualified to provide coaching (the American Pharmacists Association offers one such course). Pharmacists who were certified diabetes educators and/or board-certified in pharmacotherapy did not have to complete such training. Pharmacists generally paid for this training on their own, although some networks provided financial assistance.
  • Evaluating program impact: The American Pharmacists Association Foundation collected and analyzed data to evaluate the impact of the program on clinical and economic outcomes. These data were reported back to participating employers on a periodic basis.

Resources Used and Skills Needed

  • Staffing: Each trained pharmacist handled between 5 and 200 patients, depending on how much time they wanted to dedicate to the program and the number of participants in the region. Most networks tried to encourage pharmacists to dedicate a meaningful amount of time (and thus have a relatively large caseload), as the quality of the coaching usually increases as the pharmacist gains experience.
  • Costs: Data on the costs that participating employers paid for the coaches and reduced copayments are not available. As noted previously, these costs—plus the added expense associated with greater medication use—were outweighed by savings in other areas.

Funding Sources

GlaxoSmithKline provided funding to support the provision of consulting support to participating employers and to fund data collection, analysis, and reporting. As noted, participating employers covered the costs of the reduced/waived copayments and the pharmacists' time.

Tools and Resources

Regional Network contact information available at: http://www.healthmaprx.com/contact_us.

Information on HealthMapRx, LLC is available at http://www.healthmaprx.com. This site also includes links to other related resources.

Patient testimonials about a HealthMapRx implementation in Lancaster, PA, (known as the Lancaster Bridge project) can be found at http://www.lcbgh.org/bridge.htm. Click on the link in the end of the box titled “BRIDGE Project—Participant Testimonial Video (Right-Click to Download).”

Getting Started with This Innovation

  • Engage corporate leaders: This program will not be effective if it is run autonomously by an outside vendor (as occurs with many “disease management” programs). The return on investment will depend greatly on the quality of communications about the program within the employer organization, which, in turn, will be a function of leader engagement.
  • Set up adequate incentives: Companies that do not create an adequate incentive will see lower participation rates. For companies with already low drug copayments, it may be necessary to layer on additional incentives, such as providing “wellness points” to participants (if the company has a wellness program) or waived copayments in other areas (e.g., for primary care visits).

Sustaining This Innovation

  • Balance size of pharmacist network with access concerns: HealthMapRx used to work with local networks to ensure easy access for participants.

Use By Other Organizations

Approximately 80 employers have adopted the basic elements of this program (i.e., pharmacist coaching and reduced or waived copayments for diabetes-related drugs and supplies through the HealthMapRx program). HealthMapRx had also developed a similar, employer-based program targeted at cardiovascular disease, which provides pharmacist coaches and reduced/waived copayments for lipid-lowering agents and blood pressure medications.

Lessons Learned

The program may be especially appealing to self-insured employers, as they will benefit from the improved health of their employees, higher employee satisfaction, and any cost savings generated.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Toni Fera, BPharm, PharmD
Independent Healthcare Consultant
Pittsburgh, PA
E-mail: ferat26@hotmail.com

William M. Ellis, BPharm, MS
Executive Director
Board of Pharmacy Specialties
2215 Constitution Avenue, NW
Washington, DC 20037-2985
Phone: (202) 223-7195
E-mail: wellis@aphanet.org



Innovator Disclosures

Dr. Fera and Mr. Ellis have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Fera T, Blumi BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3):383-91. [PubMed]

Footnotes

  1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2007. Available at: http://www.prnewswire.com/mnr/dtccfinaldata/37319/docs/37319-NEW_CDC_National_Diabetes_Fact_Sheet.pdf.

  2. American Diabetes Association. Diabetes statistics. Available at: http://adap-old.pub30.convio.net/diabetes-basics/diabetes-statistics/.

  3. Fera T, Blumi BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc. 2009;49(3):383-91. [PubMed]

  4. Beckles GL, Engelgau MM, Narayan KM, et al. Population-based assessment of the level of care among adults with diabetes in the U.S. Diabetes Care. 1998;21(9):1432-8. [PubMed]

  5. Choe HM, Mitrovich S, Dubay D, et al. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11(4):253-60. [PubMed]

Funding Sources

GlaxoSmithKline

Developers

American Pharmacists Association Foundation, HealthMapRx, LLC

The American Pharmacists Association Foundation is located in Washington, DC. HealthMapRx, LLC is no longer an active organization.

Original Publication: 09/16/09

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 02/12/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 09/27/13

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information: verify here.