Impact of Value-Based Diabetes Care on the Pharmacy

Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; and Steven Peskin, MD, MBA, examine the benefits of value-based payment models for the pharmacy and the long-term impact on diabetes-related outcomes.

Troy Trygstad, PharmD, MBA, PhD: Let’s do a radical hypothetical, Dhiren. The radical hypothetical is: a purchaser comes to your practice. I want you to imagine your typical practice across the country. The purchaser says, “Fifty percent of your reimbursement is going to be dependent on getting patients to go on hemoglobin A1C.” So, the purchaser walks in and says that to the office manager. You’re sitting, visiting a patient, and the office manager says, “We need to have a team meeting.” What happens to you, as that pharmacist in the practice, if anything? What would you imagine would happen if that purchaser went to that office manager and said, “Fifty percent of all revenue is now going to be tied to hemoglobin A1C”?

Dhiren Patel, PharmD: You had mentioned that there was a hypothetical. Here it’s actually turning into a reality if we kind of think about where things are headed. I think I would welcome something like that, as you see value-based contracts being formed with certain medications and the cost associated with some of them. Right? So, you do these trials. In the clinical trials, the results are X. In the real world, it doesn’t translate into that. So, I don’t know if A1C is the only marker to look at. There may be a variety of them that you would need to look at. Again, A1C only tells a very small picture in the journey of a patient that has diabetes. But I think that, again, it helps with that alignment. You have a manufacturer who’s making this drug. They are charging X. But if it’s not, on the receiving end of it, translating to those outcomes, should they have a responsibility? Should the patient have a responsibility? Should the provider have a responsibility? Because anything that folks have a stake in, or there’s some skin in the game, that’s where you’re going to start seeing results. That should be happening.

Troy Trygstad, PharmD, MBA, PhD: But importantly, I want you to imagine that, prior to that day where that purchaser walked into that office manager’s office, you’re in a fee-for-service model, paid for doing. And then, that day, they walk in and say, “Fifty percent of revenue is tied to hemoglobin A1C,” or some similar set of cornucopia of measures. How does the practice change its view of you, if at all? How does your day-to-day work change when that shift happens?

Dhiren Patel, PharmD: I’ve been in that system for almost 10 years now. That shift happens if there’s less of, “I do this, you do this,” because it’s all coming out of 1 pocket, 1 bucket. And so, it’s basically, “Get the patient to goal.” It doesn’t matter who does it, because we’re all on the same team. You were talking about that silo. You go to that specialist, “I’m only in charge of your eyes.” “I’m only in charge of your feet.” “I’m only in charge of your heart.” But in our situation, in our system, that’s my vet forever. They’re always going to cost us. So, if I do something now, I’m benefiting from that. Whereas, you don’t see that in all systems. They may not be my member next year. They’ll be someone else’s problem, right?

Troy Trygstad, PharmD, MBA, PhD: Diabetes is almost like an exemplar disease state. We’ve already discussed that it’s very rare that the patient just has diabetes. You’ve got metabolic syndrome. Oftentimes you have behavioral health challenges. And you might have environmental home conditions along with that.

Steven Peskin, MD, MBA: Social determinants.

Troy Trygstad, PharmD, MBA, PhD: So, you’ve got this exemplar condition. But what you’re saying is, diabetes really becomes one of the key disease states that is prominent in payment and health-system reform because it touches so many patients. It touches so many comorbidities and so many parallel disease states. It really forces a system to be paid differently and operate differently, right? And so, back to the sort of policy and plan perspective, do you have some specific projects where you’ve seen some success and at least nibbling around the edges of this sort of team-based pay-for-performance? How is it that the purchaser can kind of encourage this environment?

Steven Peskin, MD, MBA: Sure. We’re absolutely all in on this whole construct: team-based care, collaborative care models. We set up our payment model to reward that, whether it be around the bundle payment for certain discrete situations like, maybe, joint replacement. Diabetes is so all-encompassing. For any attributed population, whether it be Richard’s attributed population or some other clinician here in New Jersey, diabetes is going to be. So, it’s not a diabetes-specific program. Rather, it’s around how we do the redesign, the process improvement, and the PDSA (Plan-Do-Study-Act) cycles. They will frequently involve diabetes. We did a study with one of our high-performing groups in New Jersey. We had 100 patients who got usual care. This group got some very, very high level of care. And then, 100 patients got peer coaching. The persons who got the peer coaching had better outcomes and higher levels of satisfaction. So, that’s an example.

We are looking at some of the diabetes prevention programs. We haven’t selected one, specifically. But that’s certainly something we’re very intrigued by. That kind of brings in the whole era of the digital self and digital health and how we get patients’ information to them. It seems like everybody’s tethered, for good or for ill, to their smartphone. So, we see that as a way to get information to persons or communicate with persons, whether the person be age 8 or age 88. So, that’s another aspect that we’re looking at: How do we have more of this on-demand kind of care and information?