The Pharmacist's Value in Team-Based Diabetes Care

Troy Trygstad, PharmD, MBA, PhD; Steven Peskin, MD, MBA; Richard Wynn, MD; and Dhiren Patel, PharmD, share insight into how they have altered the way they practice toward a true team-based care model that focuses on improving outcomes in type 2 diabetes mellitus.

Troy Trygstad, PharmD, MBA, PhD: Tripp, in your career, when was it that you had that “Aha” moment of alignment? “This is how I need to change our business. This is how I need to relate to the rest of the health care system.” What prompted it, and what was that experience?

Tripp Logan, PharmD: I know exactly what it was. We had a patient walk into the pharmacy. My father and I were working that day. I could hear our technician say, “Sir, blah, blah.” So, I went over and I said, “Bonnie, what’s going on?” And she said, “This patient walked in with this prescription, but we don’t have it. I told him that we would have it tomorrow.” “Great.” What it ended up being was, it was an HIV patient from a small rural area at the time. We weren’t doing much HIV. We wrote $4000 worth of medicine for which we didn’t have in stock. But with the next day delivery, we were going to have it. No big deal. The next day, the drug showed up. We were ready to go. The patient didn’t show up. Two weeks later, dad looked at me and said, “You’ve got $4000 worth of medicine on the shelf. Send it back.”

Two days after that, guess what happened? The guy walks back in. He wants his medicine. We looked at each other. We totally failed. We failed the patient. We failed our business. We failed their provider. Did we call them? Did we talk to their provider when they hadn’t picked it up? We failed everybody. So, we completely changed our entire practice based on that single event.

Troy Trygstad, PharmD, MBA, PhD: And for you, Dr. Wynn, did you have an “Aha” moment at some point in your career trajectory where you said, “Practicing the way I started practicing, it’s going to be tough if it takes a village”? What was that moment? How did it change? You said, “I’m going to think about this differently.” And, “Here’s what I’m going to do differently.”

Richard Wynn, MD: I’m not sure that there was one moment. There were several things that made me think about medicine very differently. A lot of them revolve around deaths of patients that were unnecessary. There was a particular patient, who I remember, that was trying very hard. She had a lot of psychiatric comorbidities. She had a lot of anxiety issues and was very anxious to please. She didn’t tell us the whole story. She didn’t tell us why she wasn’t taking something or doing something. She didn’t tell us that she was living on disability income, which barely covered her rent, left a few dollars for her food, and left nothing for medications. She had insurance but couldn’t afford the co-pays. We were shopping around for medications, and she wanted us to get samples for her. There were different pharmacists involved, and she just fell through the cracks. We just were not able to help her. That was very frustrating because the resources were there.

Troy Trygstad, PharmD, MBA, PhD: You said at that moment you wanted to do pharmacy differently, essentially?

Richard Wynn, MD: Oh, yes. There’s got to be a better way to do this.

Troy Trygstad, PharmD, MBA, PhD: So, here’s a tough question. The majority of health care in this country is purchased by 2 groups: employers and taxpayers. As a plan, our sense is that employers and taxpayers aren’t particularly happy about how we not only set up the health care system but, in particular, how we try to leverage our investment in medications. Right? That’s what we use medications for. They’re a modality to prevent some downstream disease progression or poor outcome. What are employers and taxpayers telling you about how they want to see things done differently so that we create performance alignment and patient alignment? How do we create this alignment, where we do care differently in a team-based model and so on and so forth? What are they telling you as sort of a purchaser community?

Steven Peskin, MD, MBA: All of us wear a certain business hat. We talk about return on investment. Really, what we’re looking at is return on health, right? So, the investment that we’re making as a society—plan sponsors that you mentioned, purchasers, employers, the government being the largest single purchaser of health—we’re really looking for a return for that. We’re looking for better health outcomes. We’re looking for persons to be aware, that notion of patient experience. Again, we’re looking for affordability.

We look at what are we are getting and what kind of value we are getting. That’s where we’re really shifting significantly, from pay-for-volume to pay-for-value. And so, how do we define that value? Again, that value is defined on total cost of care. We look at a particular system. We would look at Dr. Wynn’s practice and we’d say to him, “Here’s how you’re doing with the persons that are in your practice.” We call that attribution. So, you have an attributed population. And then, we look at how you’re doing around key quality measures. Again, the measurement of quality is an imperfect science. We know that everything that is measured doesn’t matter. And we know that everything that matters isn’t measured. So, we are still struggling there. But for what measures we do have, and for what measures that are perceived as having a significant impact on a chronic condition like diabetes, we assiduously measure those things.

And then again, we look at how persons are experiencing their care. When I was hearing my colleagues talk, I was thinking about the great work that they do and this notion of the person or family and patient-centered care. Again, it’s not about us doing things to people. It’s about us doing things with people. One of my heroes, Dr. Berwick, talks about radical redesign. He talks about changing the balance of power. That’s such a powerful statement. That is such a profound statement. So, again, it’s not this paternalism of “The pharmacist knows best. The nurse knows best. The doctor knows best. The health care CEO knows best.” Rather, it’s asking, “What are you looking for? What are your goals?” And, similarly, “What are your family’s goals?”