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Population health approach to diabetes sweetens outcomes
Population Health Drives Cost Savings in Diabetes
By Jillian Mock Denver—In North Carolina, a local hospital system partnered with a health insurer to implement a population health program to reduce costs and increase care quality for patients with diabetes. The program illustrates how pharmacists can use detailed data to bolster value-based care efforts, according to the case study presented at AMCP Nexus 2021.
“The key to our population health team is robust data,” said co-investigator Molly Hinely, PharmD, BCPS, the pharmacy clinical coordinator for population health at Atrium Health Wake Forest Baptist. “Where do we get that data? We get it from the health payor.”
In the United States, spending on diabetes care doubled in a 10-year period, from $116 billion in 2007 to $237 billion in 2017, according to the American Diabetes Association (ADA) (Diabetes Care 2020;43[10]:2396-2402). The costs of institutional care decreased from 2012 to 2017, but spending on outpatient services, medications and supplies increased (Diabetes Care 2018;41[5]:929-932).
In North Carolina, about 11.3% of the adult population was diagnosed with diabetes in 2019, according to the ADA (bit.ly/3Dxu3WK), compared with 10.8% in the country as a whole, according to the CDC (bit.ly/3pTqy8j).
On the payor side, Blue Cross Blue Shield of North Carolina (BCBSNC) has an advanced payment model program (called Blue Premier) that links costs and fees to quality and value of care. As part of that program, the researchers looked at data collected on prescribed medications, fill history and care gaps. “The data we collect support our mis-
sion of making prescription drugs more affordable and improving outcomes for members,” co-investigator Brenden O’Hara, RPh, BCACP, a clinical pharmacist at BCBSNC, said in an email interview. Improving collaboration between payor and provider groups is a huge focus for the program, he noted.
In 2021, Mr. O’Hara and his team focused on providing data to healthsystem pharmacists that could translate into immediate savings. This included identifying opportunities for providers to move patients to more affordable, clinically equivalent alternative medications, prescribing more affordable and effective combination therapies, and implementing real-time benefit checks, Mr. O’Hara said.
“I am witness to the fact that the information they’re able to provide for the health systems is extremely helpful to us,” Dr. Hinely said during the meeting presentation.
Dr. Hinely’s population health team is heavily focused on value-based pharmacy services, she noted, working in various care settings including rural health in Catawba County and the WinstonSalem urban center. Atrium Health has five campuses, one academic medical facility, four community hospitals, and nine community and specialty pharmacies, she said. Although Dr. Hinely’s team works with Medicare and Medicaid health plans and contracts, the department’s largest contract is commercial
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with BCBSNC, with a patient population made up largely of working families.
Day to day, the collaboration between Dr. Hinely’s team and Mr. O’Hara’s team primarily takes the form of data-driven reports, including assessments detailing ineffective medication combinations and total cost of care. The data in these reports include basic biographical information—patient name, date of birth, provider—and the medications the patient is taking, and quality health measures such as hemoglobin A1c, blood pressure and adherence to prescribed antidepressants,
Dr. Hinely said. The reports are built directly into the customized electronic health record (EHR), in which the pharmacists can also document everything, communicate recommendations to providers, and reach out to patients if they cannot be contacted by phone.
Collaborating Across Different Sites of Care
“For me, the biggest takeaway I wanted everyone to get was the importance of collaboration among different pharmacy work areas,” Dr. Hinely said.
Dr. Hinely’s team of population health pharmacists work with the health payor (BCBSNC), information technology experts, data analysts, quality team, and pharmacy students and residents to make the most of available data, she said. The resulting data reports enable her team to triage patients and determine which patients need a pharmacist’s review, she noted.
Within the diabetes case study, BCBSNC and its partners in the program found $36,800 in savings by valueprescribing metformin extended release (transitioning from metformin ER to a more affordable, clinically equivalent alternative medication).
This amount was out of an initially projected $64,509 in savings, indicating there are still opportunities to implement education, real-time benefit checks and increase messaging through the EMR, Mr. O’Hara noted. The cost savings did not include savings generated from requiring prior authorization on some high-cost prescription drugs to treat patients with diabetes, according to Mr. O’Hara. Metformin ER was one of 25 high-cost medications that BCBSNC identified as easy to switch with a lower cost, clinically equivalent alternative.
By identifying opportunities to deprescribe ineffective medication combinations (and prescribe more effective and affordable combination therapies), BCBSNC and its partners generated $473,580 in initially calculated savings by July 2021, out of an initially projected $798,624 in savings, Mr. O’Hara said.
“Getting useful data in as close to real time as possible is an ongoing challenge,” he noted, adding that his team also has to figure out how to track progress and create clear reports that provider groups like Atrium Health can use to achieve particular outcomes and benefit patients.
At the end of the day, Dr. Hinely and her team of pharmacists continue to rely on providers to look at and accept their recommendations, which can be particularly difficult when there is no follow-up visit scheduled, she said during the presentation. Furthermore, there are so many diabetes medications out there—an “alphabet soup” of options, she said.
“There’s still a lot of education around correct diabetes regimens that still needs to happen,” Dr. Hinely said. “I think diabetes is becoming one of the hardest disease states to treat with the amount of therapies that we have.”
The sources reported no relevant fi nancial disclosures.
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