Uncovering Reasons for Missed Targets in Diabetes

FEBRUARY 22, 2018


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; and Tripp Logan, PharmD, examine the need for careful evaluation of the potential reasons why diabetes treatment targets are not being reached.

Troy Trygstad, PharmD, MBA, PhD: Can you think of a scenario where the factors aren’t necessarily related to the patient not following their plan? And the conventional therapies, for whatever reason? One of my follow-up questions is going to be, what are some of the things that we need to think about, before it’s even regimen-setting time with patients, even from a biomedical perspective? So, it’s not just the patient’s goals, but a patient is following their plan. What’s that look like? “Hey, this didn’t work. What’s next?”

Richard Wynn, MD: What happens, generally, is that I’ve misunderstood something. There is some piece of information that I’m sure of, that’s not correct.

Troy Trygstad, PharmD, MBA, PhD: Interesting.

Richard Wynn, MD: So, I’m going back and doing a home visit. “The 5-mile walk you were taking your dog on, the dog died 3 years ago. So, things have changed. There’s something, a new factor, that’s introduced that I wasn’t aware of before. There’s a misunderstanding going on. You’ve got to go back to the beginning and start over again. You’ve got to work with the patient as a new patient.

Troy Trygstad, PharmD, MBA, PhD: If I would have sat at this table 10 years ago, it would have been a scenario where we would have had a biomedical conversation. There’s no question about that. I think you see this a lot but particularly when you’re out there in the wild, out in a community-based pharmacy scenario. In our community, in Tripp’s and my world, we call these drug misadventures. How do we get to a point of polypharmacy?

We had one scenario in a health system where we embedded a pharmacist at discharge. When you looked at all of the medicines on the discharge, all of the medicines on the PCP chart, and all of the medicines that were in the pharmacy dispensing, it was non–heme-oncology, nonlabor and delivery, typical discharge, and 26 different medications. What’s interesting about this conversation is, we had a conversation about going back. This wouldn’t have been the case 10 years ago, I practically guarantee it, where you would have said, “Hey, the care plan didn’t execute what we wanted. I’m going to do a further investigation before I go and just turn on another spigot.” Right?

Steven Peskin, MD, MBA: Sure.

Richard Wynn, MD: Oh, yes.

Troy Trygstad, PharmD, MBA, PhD: That’s an interesting practice, I believe.

Steven Peskin, MD, MBA: We’ve been very, very pleased with working with our pharmacy department, in my organization, with the medication therapy management and the comprehensive medication review. We will send out PharmDs, into the wild, into the practices. This practice says, “Yes, it’s OK if you send one of your people over here. We’ll appreciate your help,” rather than look at you as the evil payer.” So, that has been a real improvement.

You have a trained person who has good interpersonal skills. She or he goes into practice “X” and is there on behalf of both ourselves and the practice to look at the medication conundrum. And again, it may be attenuating this one, stopping this one, increasing the dose—giving some really thoughtful recommendations and allowing our pharmacy colleagues to really be a part of the team.

Troy Trygstad, PharmD, MBA, PhD: What you framed there was from a plan perspective.

Steven Peskin, MD, MBA: Yes.

Troy Trygstad, PharmD, MBA, PhD: But as a provider perspective, there was certainly a period of time, over multiple decades, where Tripp, out in the community pharmacy, was viewed as the drug cost police. Right? “Yes, you can help. You’re the drug cost police.” How has that changed, over the last few years, as we’ve gotten into payment reform and holding providers accountable for outcomes? You have a thriving practice, with respect to reinforcing and helping the patient with their care plan. What is the rule now that you might play with therapeutic selection? Or “Hey, here’s what I see going on.” Or you are working with a practice across the street. You’re in a relatively rural area. You’ve got a community of folks that are providers, but they may not have somebody that’s there, full time, in a practice, who has a drug information resource and may be doing lunch and learns and all these sorts of things. What is the role of that community pharmacy, out there in rural America, with the family practice across the street? You’ve got the specific patient stuff, but what about, do you go have a beer at the bar and say, “Hey, have you seen the latest drug out there? What do you think about it? Here’s what I think about it.” What does that dynamic look like in 2017 versus in 1997?

Tripp Logan, PharmD: In our practice, when we get a new pharmacist on board or new resident–we’ve got students rotating through–or I also do this with the colleagues that I work with, it’s important to make everybody in the community understand that you’ve got somebody who is a train wreck. You get a complex, really, really tough patient. “We need to send them to these guys.” I think having that reputation is really important. You build that reputation over time. You can’t go in, over a beer, and have a sales sheet and get to that point. So, that’s relationship building.

The big advantage that community pharmacy has, right now, is that most community practices have been there for a really long time. They’ve had the ability to build those relationships or they’ve already broken down some of those barriers. So, those relationships can be built pretty quickly.

Then, I’ll go back to the whole iceberg philosophy: Just because you walk into a pharmacy, and this is what you see, that doesn’t always mean that’s what’s happening. So, we need to be better about making sure that our payer partners, that our provider partners, understand what we’re doing on the back side. We need to be better about visiting the patient’s homes and making sure that these patients are getting regular check-ins from the pharmacy.

A lot of them are, from a business standpoint, from the pharmacy, making sure that the prescriptions are filled, that workflow is consolidated, and it’s good. But it benefits everybody upstream and downstream.

One other thing is quality of life. We’ve got so many patients that we see that who are sticking to their regimen. They’re doing a really good job, but their quality of life is terrible. You’ve got a provider in your community asking, “How are things?” How is your quality of life? What’s going on?” It’s amazing how many walls that tears down, just in itself. We can get to the root of what this problem is. Then, we learn about the dog dying. That’s when we figure those things out. So, quality of life is really important. I didn’t want to get through this discussion without that being brought up.
 


Troy Trygstad, PharmD, MBA, PhD; Richard Wynn, MD; Steven Peskin, MD, MBA; and Tripp Logan, PharmD, examine the need for careful evaluation of the potential reasons why diabetes treatment targets are not being reached.

Troy Trygstad, PharmD, MBA, PhD: Can you think of a scenario where the factors aren’t necessarily related to the patient not following their plan? And the conventional therapies, for whatever reason? One of my follow-up questions is going to be, what are some of the things that we need to think about, before it’s even regimen-setting time with patients, even from a biomedical perspective? So, it’s not just the patient’s goals, but a patient is following their plan. What’s that look like? “Hey, this didn’t work. What’s next?”

Richard Wynn, MD: What happens, generally, is that I’ve misunderstood something. There is some piece of information that I’m sure of, that’s not correct.

Troy Trygstad, PharmD, MBA, PhD: Interesting.

Richard Wynn, MD: So, I’m going back and doing a home visit. “The 5-mile walk you were taking your dog on, the dog died 3 years ago. So, things have changed. There’s something, a new factor, that’s introduced that I wasn’t aware of before. There’s a misunderstanding going on. You’ve got to go back to the beginning and start over again. You’ve got to work with the patient as a new patient.

Troy Trygstad, PharmD, MBA, PhD: If I would have sat at this table 10 years ago, it would have been a scenario where we would have had a biomedical conversation. There’s no question about that. I think you see this a lot but particularly when you’re out there in the wild, out in a community-based pharmacy scenario. In our community, in Tripp’s and my world, we call these drug misadventures. How do we get to a point of polypharmacy?

We had one scenario in a health system where we embedded a pharmacist at discharge. When you looked at all of the medicines on the discharge, all of the medicines on the PCP chart, and all of the medicines that were in the pharmacy dispensing, it was non–heme-oncology, nonlabor and delivery, typical discharge, and 26 different medications. What’s interesting about this conversation is, we had a conversation about going back. This wouldn’t have been the case 10 years ago, I practically guarantee it, where you would have said, “Hey, the care plan didn’t execute what we wanted. I’m going to do a further investigation before I go and just turn on another spigot.” Right?

Steven Peskin, MD, MBA: Sure.

Richard Wynn, MD: Oh, yes.

Troy Trygstad, PharmD, MBA, PhD: That’s an interesting practice, I believe.

Steven Peskin, MD, MBA: We’ve been very, very pleased with working with our pharmacy department, in my organization, with the medication therapy management and the comprehensive medication review. We will send out PharmDs, into the wild, into the practices. This practice says, “Yes, it’s OK if you send one of your people over here. We’ll appreciate your help,” rather than look at you as the evil payer.” So, that has been a real improvement.

You have a trained person who has good interpersonal skills. She or he goes into practice “X” and is there on behalf of both ourselves and the practice to look at the medication conundrum. And again, it may be attenuating this one, stopping this one, increasing the dose—giving some really thoughtful recommendations and allowing our pharmacy colleagues to really be a part of the team.

Troy Trygstad, PharmD, MBA, PhD: What you framed there was from a plan perspective.

Steven Peskin, MD, MBA: Yes.

Troy Trygstad, PharmD, MBA, PhD: But as a provider perspective, there was certainly a period of time, over multiple decades, where Tripp, out in the community pharmacy, was viewed as the drug cost police. Right? “Yes, you can help. You’re the drug cost police.” How has that changed, over the last few years, as we’ve gotten into payment reform and holding providers accountable for outcomes? You have a thriving practice, with respect to reinforcing and helping the patient with their care plan. What is the rule now that you might play with therapeutic selection? Or “Hey, here’s what I see going on.” Or you are working with a practice across the street. You’re in a relatively rural area. You’ve got a community of folks that are providers, but they may not have somebody that’s there, full time, in a practice, who has a drug information resource and may be doing lunch and learns and all these sorts of things. What is the role of that community pharmacy, out there in rural America, with the family practice across the street? You’ve got the specific patient stuff, but what about, do you go have a beer at the bar and say, “Hey, have you seen the latest drug out there? What do you think about it? Here’s what I think about it.” What does that dynamic look like in 2017 versus in 1997?

Tripp Logan, PharmD: In our practice, when we get a new pharmacist on board or new resident–we’ve got students rotating through–or I also do this with the colleagues that I work with, it’s important to make everybody in the community understand that you’ve got somebody who is a train wreck. You get a complex, really, really tough patient. “We need to send them to these guys.” I think having that reputation is really important. You build that reputation over time. You can’t go in, over a beer, and have a sales sheet and get to that point. So, that’s relationship building.

The big advantage that community pharmacy has, right now, is that most community practices have been there for a really long time. They’ve had the ability to build those relationships or they’ve already broken down some of those barriers. So, those relationships can be built pretty quickly.

Then, I’ll go back to the whole iceberg philosophy: Just because you walk into a pharmacy, and this is what you see, that doesn’t always mean that’s what’s happening. So, we need to be better about making sure that our payer partners, that our provider partners, understand what we’re doing on the back side. We need to be better about visiting the patient’s homes and making sure that these patients are getting regular check-ins from the pharmacy.

A lot of them are, from a business standpoint, from the pharmacy, making sure that the prescriptions are filled, that workflow is consolidated, and it’s good. But it benefits everybody upstream and downstream.

One other thing is quality of life. We’ve got so many patients that we see that who are sticking to their regimen. They’re doing a really good job, but their quality of life is terrible. You’ve got a provider in your community asking, “How are things?” How is your quality of life? What’s going on?” It’s amazing how many walls that tears down, just in itself. We can get to the root of what this problem is. Then, we learn about the dog dying. That’s when we figure those things out. So, quality of life is really important. I didn’t want to get through this discussion without that being brought up.
 
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