Diabetes is the most expensive chronic health condition in the United States. Medical expenses for people with diabetes cost approximately $9,600 more annually than individuals who don’t have this disease, the American Diabetes Association (ADA) reports. In 2017, costs of diabetes care amounted to a staggering $237 billion in direct medical costs and $90 billion in reduced productivity, according to a 2018 

, for a total of $327 billion-an increase of 26% since 2012.

The largest contributors to the cost of diabetes are higher use of prescription medications beyond diabetes medications ($71.2 billion); greater use of hospital inpatient services ($69.7 billion); medications (oral agents and insulin-approximately $15 billion for insulin alone); supplies to directly treat diabetes ($34.6 billion); and more office visits to physicians and other healthcare providers ($30 billion).

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Among the two types, type 2 diabetes is much more common-the 

29 million cases. This disease usually begins when muscle, liver, and fat cells misuse insulin. Consequently, the pancreas produces more insulin to keep up with increased demand. But over time, the pancreas can't make enough insulin and blood glucose levels rise.

About 1.25 million Americans have type 1 diabetes. This occurs when an infection or another trigger causes the body to mistakenly attack cells in the pancreas that produce insulin, making insulin replacement therapy essential.

Given its high cost and prevalence, finding better ways to treat this disease are vital. Here are  five new advances in disease management.

FDA-approved in December 2017, Ozempic (semaglutide) is the newest diabetes medication in the United States, says Schafer Boeder, MD, endocrinologist and assistant professor of medicine of the 

, University of California San Diego. As a GLP-1 receptor antagonist, it works by increasing insulin secretion when eating meals and slowing down digestion. It also decreases the release of glucagon, a hormone that acts in opposition of insulin and raises blood glucose. Semaglutide reduces average blood glucose levels without increasing hypoglycemia (a state of low blood sugar levels). It also decreases appetite and promotes weight loss.

 had favorable results. It showed a 26% reduction in the combined outcome of cardiovascular death, nonfatal heart attack, or nonfatal stroke (mostly due to decreased heart attacks in patients taking the drug), Boeder says. This medication improves blood glucose control, which leads to reduced incidences of expensive complications such as eye, renal, and vascular disease, and heart attack.

SGLT-2 inhibitors, such as Farxiga (dapagliflozin) and Jardiance (empagliflozin) comprise a newer class of diabetes drugs established in 2013. These oral medications, taken once daily, help reduce blood glucose levels through a unique mechanism that eliminates more sugar than normal through urination. “By removing excess sugar from the body before it's absorbed, patients may have minor weight loss,” says Hester Hommel, PharmD, MPH, CDE, a specialist pharmacist at 

 in Fairfield, Ohio. “These medications also tend to remove excess water from the body, which can lower blood pressure.”

Recent studies show that these drugs produce favorable outcomes, including fewer cardiac events and a lower risk of heart failure. “These added benefits may reduce the number of medications patients need, and may also reduce the need for costly hospitalizations and procedures related to heart disease,” Hommel says.

Concentrated Humulin R U-500 (insulin human injection), which is prescribed to patients with high insulin needs, is now available in a prefilled pen. “This improves ease of administration and reduces the chance of dosing errors (which can lead to devastating low blood glucose events and additional hospitalizations,” Boeder says.

Other concentrated insulins, U-200 degludec (Tresiba) and U-300 glargine (Toujeo), both act as ultra-long acting basal insulins, given once daily. “They have slightly less variability throughout the day than other basal insulins, and have lower hypoglycemia rates,” Boeder says.

“These products are good options for patients who need larger doses of insulin, including those who have insulin resistance, which is common in individuals with type 2 diabetes,” Hommel says. Previously, patients who needed high doses of insulin had to endure multiple injections, which often caused discomfort, scarring, and irregular absorption.

3. Glucose monitoring devices and sensors

 continuous glucose monitoring system and Abbott’s 

 continuous glucose monitoring system, allow patients to monitor their blood sugar throughout the day without sticking their finger to obtain a blood sample, Hommel says. The patient wears a sensor that has a small wire inserted into the skin. The sensor continuously measures glucose levels in surrounding tissues, which correlates to glucose levels in the blood. Sensors can be worn for several days, before needing a new one. Some systems can communicate with an insulin pump to help regulate an insulin dose automatically.

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“This technology is best for patients who use insulin,” Hommel says. “It gives both the patient and healthcare provider far more data points to evaluate their diabetes control than they would get from finger-stick testing. Changes in blood sugar can be more easily detected and the cause for the change can be more readily identified. Some systems have an alarm feature to warn patients when their blood sugar is trending out of range, thereby preventing dangerously low blood sugars and allowing patients to act more quickly.”

“Low blood sugars can be very dangerous and require emergency treatment, so preventing those occurrences can help to avoid unnecessary costs of care,” Hommel says. The extra data acquired by monitoring sugars 24/7 can improve blood sugar control, and has been shown to 

In February 2018, the FDA approved Medtronic’s 

 for patients with type 1 diabetes. The device is a combination of a continuous glucose monitoring device and an insulin pump that delivers the insulin dose. “The two devices communicate and adjust insulin flow to more closely mimic normal pancreatic function,” Hommel says. “Patients still have to count carbohydrates and give a dose of insulin from the pump before eating.”

“This type of system can more closely regulate insulin and blood sugar levels and can respond to both high and low blood sugar levels without a patient’s manual input,” Hommel says. “This is a good option especially for children with type 1 diabetes who have difficulty controlling blood sugars.”

Patients using this system have been shown to have better control and fewer episodes of both low and high blood sugars. A1c levels are improved and patients have fewer medical emergencies from hypoglycemia or diabetic ketoacidosis, a dangerous condition that develops when blood sugars are extremely high, Hommel says.

Boeder adds that more advanced artificial pancreas systems, including fully closed-loop systems that can give insulin doses when needed to cover meals or high glucose levels, remain in clinical trials.

Manufactured by Xeris Pharmaceuticals to treat severe hypoglycemia, the ready-to-use 

 is currently under FDA review. “Xeris has developed a stable glucagon solution that is pre-loaded in an auto-injector pen,” Boeder says. “It is for a second party to use when an individual has severe hypoglycemia and is unable to treat themselves.”

“This device is much easier to use and therefore more reliable than the current glucagon rescue kit, which requires multiple steps to properly administer,” Boeder says. It could help treat hypoglycemia and prevent hypoglycemia-related death and hospitalizations.”

With costs of diabetes care at record highs, health insurers are taking innovative steps to prevent diabetes, control costs of care, and improve the quality of care. Here are five current initiatives.

 has launched a CDC-recognized Diabetes Prevention Program (DPP) that targets individuals with pre-diabetes, a condition in which blood sugar levels are elevated, but not high enough to be diagnosed with diabetes, says Richard Seidman, MD, MPH, chief medical officer of the Los Angeles, California-based insurer, the largest publicly-operated health plan in the country.

 shows that individuals with pre-diabetes who lose 5% to 7% of their body weight can reduce the risk of developing type 2 diabetes by 58%. The DPP’s goal is to promote behavior change that results in healthier eating, increased physical activity, and at least 5% body weight loss. A trained lifestyle coach teaches the year-long program.

The program is available at more than 150 locations across Los Angeles County, in addition to eight online programs, Seidman says. For members who can’t commit to a year-long program, LA Care offers in-person health education workshops for pre-diabetes, in addition to telephonic diabetes education with a dietitian. Members may also access an online health portal for workshops, a comprehensive health education library, healthy recipes, and general information from a health coach.

LA Care offers an ADA recognized diabetes self-management education (DSME) program for members diagnosed with type 1 or 2 diabetes. DSME consists of telephonic diabetes education with a registered dietitian over four months. At the end of the intervention, more than 70% of members reported that they were meeting their personal goals for monitoring, taking medication, problem solving, healthy eating, being active, and reducing risks.

Additionally, LA Care contracts with a vendor that provides in-person DSME and will soon add telehealth as a delivery mode to increase access and improve cost effectiveness, Seidman says. LA Care has five family resource centers across the county that offer additional support to members with diabetes, including free workshops and exercise classes.

LA Care offers a diabetes disease management program to all members with diabetes. They receive interventions based on their severity level. Members of all severity levels receive a welcome packet and annual health education mailings, and members stratified with a higher severity level are assigned to a registered nurse for telephonic condition monitoring. They receive appropriate referrals such as social work, community programs, and dietitian services. The program provides a comprehensive, coordinated approach to improve members’ clinical condition and quality of life.

Inpatient members with high severity diabetes who didn’t have the intervention experienced 202% more inpatient hospital admissions than those engaged with program. This equates to a $1,686 savings per member per month (PMPM). These same members who weren’t engaged in the program experienced 72% more emergency department visits than those who participated in the program. This equates to a $70 savings PMPM.

.’s (HCSC) Pharmacists Adding Value & Expertise (PAVE) program works directly with select pharmacies to promote medication adherence for Medicare, Medicaid, and retail-exchange members with a focus on disease state literacy and adherence to diabetes, hypertension, and cholesterol medications, says Jay Gandhi, vice president, Enterprise Pharmacy, HCSC. HCSC uses pharmacy claims information to provide PAVE pharmacists with insight into members’ medication adherence. Pharmacists ask patients why they aren’t adhering to their medications and how they can remember or be encouraged to do so. Since the program began in January 2016, it has expanded to reach 20,000 members. In 2018, PAVE pharmacies saw an 11% increase in medication adherence for members with diabetes.

PAVE delivers savings by working with pharmacists to educate members on their pharmacy medication to improve health outcomes, Gandhi says. The program also increases members’ medication compliance by working with providers to address or remove therapies and convert members to preferred formulary products based on the latest formulary options.

Since its start in January 2016, PAVE has expanded to reach 20,000 members. In 2018, PAVE pharmacies saw members with diabetes increase their medication adherence by 11%. 

HCSC launched a diabetic retinopathy pilot program with federally qualified health centers in Chicago. Diabetic retinopathy is the most common cause of vision loss among people with diabetes. High blood-sugar levels damage small blood vessels in the tissue that lines the back of the eye. HCSC donated hand-held digital cameras to health centers to improve screening rates for diabetic retinopathy, says Esther Morales, divisional vice president, Quality Management Programs, HCSC.

Images of the eye taken at the health centers are transmitted to eye specialists, who typically deliver a diagnostic report within 90 minutes. Participating health centers provide free screenings for any patient who needs one, regardless of their insurer. To date 1,100 patients have been scanned. Fifteen percent of patients had potential signs of diabetic retinopathy, who were referred to in-network eye specialists.

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“The program provides a method for early detection, so patients can address the condition early on,” Morales says. “Generally, the earlier any diabetes complication is identified, the better the patient’s outcomes and the less money the insurer will need to spend. Diabetic retinopathy worsens the longer patients go without treatment and can lead to blindness.”

The program’s goal is to increase patients’ access to diabetic retinopathy screenings in federally-qualified health centers. More than 1,100 patients have been screened to date.

Karen Appold is a medical writer in Lehigh Valley,

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The disease management and insurer initiatives changing the diabetes landscape.

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Provider engagement is fundamental for the success of a health system. Engagement involves a strategy that leads to a stable relationship between physicians and health systems.

There must be a top-down commitment to engagement. Leadership must establish the culture and create an action plan that results in engagement. Providers must adapt to new concepts, including value-based care models, and be meaningfully included in the process, beginning with discussions and through to implementation.

“An organization can benefit from a plan to engage its physicians proactively,” says Clint MacKinney, MD, MS, associate clinical professor at the University of Iowa 

. “Physicians will determine the success.”

In the physician-patient relationship, engagement provides an opportunity to implement clinically appropriate and efficient processes to improve care.

“We want to be engaged,” says Ralph J. Nobo Jr, MD, a 

 board member. “It’s very frustrating when we can’t be fully engaged.”

While MacKinney acknowledges that while it is difficult work, provider engagement is attainable. Here are some strategies that health systems can use to successfully engage their physicians.

When physicians are engaged, they understand how best to take care of their patients, Nobo says. In turn, patients are more likely to follow their care instructions.

“If patients feel their doctor is engaged in their care, they’re more willing to participate in that care,” he says. “I strongly believe that when patients feel their physician is engaged, they know their doctor is trying to help them.”

Traditionally, primary care physicians may only know what’s happening with their patients during an appointment, says Robin Tam, senior vice president of strategy & business development for 

, a medical group that partners with health plan networks to improve outcomes. Outside of the face-to-face interaction, physicians have little way of knowing the medical status of their patients.

ConcertoHealth attempts to bridge that disconnect by providing services through its health plan partnerships to keep physicians apprised of any developments regarding their patients in the such areas as admission and discharge activities, medications, and gaps in care.

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Physicians are delivered insights about their patients they might not otherwise know. “This is the most successful way to engage the physician,” Tam stresses.

Using its strategies of engagement, ConcertoHealth managed to reduce hospital readmission rates by 50% in its Washington market and by 16% in its Michigan market from 2016 to 2018. In addition, hospital admits per thousand were reduced by 16% in Michigan between 2017 and 2018 and emergency department visits per thousand were reduced by 17% in Michigan between 2016 and 2018.

Physicians will engage, Tam believes, if they see a commitment to helping them care for their patients.

“By offering physicians support in the time when the patient is not directly clinically engaged with them, the interaction will become more effective,” she stresses. “Patients will adhere to their treatment plans over time and get the care they need. This makes life easier for the physician.”

Nonmedical responsibilities have always been a part of a physician practice. But outside mandates-from government, hospitals, health systems, and payers and other forces completely out of their control-add to the burden of physicians.

For Nobo, it’s not convincing physicians of the importance of engagement-they already know the importance. It’s convincing outside influencers about the importance. Physicians are supposed to be the leaders in choosing the care model for their patients. Sometimes, though, physicians feel those decisions are taken out of their hands by outside forces, even if they believe it’s not in the best interest of the patient, Nobo says.

“At that point, physicians become disengaged,” he points out.

To have proper physician engagement, it’s important to have the proper dialogue with outside influencers, including hospitals, health systems and payers.

“It is not up to us; it is up to hospitals and third-party payers to allow us to be engaged,” Nobo stresses. “I should be able to speak freely, and I should be able to dictate what is the best course for the patient.”

As for their practices, a health system can provide care management services that benefit physicians and their patients by tending to some of the nonmedical needs such as making sure patients can afford their medications or can get a ride to their appointments.

“This is not a good use of a physician or nurse time but a care management program can take care of these responsibilities,” says John W. Malone, principal of 

, a Chicago-based healthcare consulting firm.

In the area of technology, providing the proper electronic tools that give physicians accurate, real-time, meaningful information on their patient population will make their jobs easier.

The goal, according to Nobo, should be to allow physicians to do what they do best: care for their patients.

“Removing unnecessary burdens will increase engagement and productivity,” he maintains. “Most importantly, it will improve patient care.”

While physicians are on the front lines of care, it is senior leadership that must establish the culture of engagement. MacKinney describes this as a CEO’s most important job.

“Engagement impacts every part of an organization, including finances,” he says. “It’s a responsibility that can’t be advocated down the line. CEOs need to be hands-on.”

At the same time, while health systems have the money to invest in infrastructures to create accountable care organizations (ACOs) and clinically integrated networks, nothing moves forward without physician participation, says William K. Faber, MD, MHCM, managing principal of Lumina Health Partners. Physicians have to participate from the beginning in any model that improves engagement. Without it, the chance of success is low.

Long-standing tensions between physicians and employer-health systems must give way to partnerships where responsibility and financial success are shared.

“No transformation effort goes forward without physicians being engaged,” Faber says. “There has to be an alignment between the incentives for physicians and incentives for the organization.”

4. Succeeding in a value-based environment

Physician engagement takes on added significance as healthcare continues to transition to value-based reimbursement models. Although many physicians continue to resist the transition, change is coming, Faber insists.

“There aren’t many places in the U.S. where it’s just fee-for-service,” he maintains. “The landscape continues to change.”

Faber says health systems should develop strategies to convince their physicians that it’s in their best interest to embrace value-based reimbursement. It’s an easy picture to paint, he points out. Often, his discussions with health system leadership focus on situations where patients leave one medical group for another that has embraced the value model of care.

Five ways to increase physician engagement

“All of sudden, the waiting room starts to clear out,” Faber stresses. “They feel it in their pocketbooks. The public is demanding value; the status quo will not serve healthcare organizations. Value is how we’re getting paid.”

As the industry moves away from the fee-for-service payment model, it is physicians who will achieve the quality and efficiency metrics that fulfill the promise of value-based reimbursement.

“Physicians have always been important to the success of a hospital or health system,” MacKinney says. “But they will be even more important as we move toward value-based care processes and value-based payments. That’s why engagement is important.”

Ken Krizner is a freelance writer based in Cleveland, Ohio. 

While it is difficult work, provider engagement is attainable. Here are some strategies that health systems can use to successfully engage their physicians.

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Witnessing his mother’s experience with cancer inspired Scott Rissmiller, MD, chief physician executive at 

-a Charlotte, North Carolina-based healthcare network that includes more than 40 hospitals and 900 care locations-to become a physician.

His mother’s journey with breast cancer included chemotherapy, surgeries, and recurrences of the disease. Rissmiller’s mother also inspired him to pursue a career in medicine because of her role as a neonatal nurse.

“She really had a passion for it,” he says. His mother passed away due to cancer when Rissmiller was 21 years old.

“When we knew that it was terminal, [I noticed] how her physician would spend time with my mom in her hospital room. Not even talking about medical things. It was just about sitting there and answering her questions. That was probably the most impactful thing that influenced my decision to go into healthcare,” he says.

The fact that her physician was completely present with his mother made an impression on Rissmiller.

“I saw the incredible impact that her physician had on not just her medical condition but on her emotional condition,” he says. “Even after she had received bad news, a quick call from her physician could keep her moving forward.”

That’s the type of physician Rissmiller wanted to be.

Also informing his career path were the financial challenges his family endured after Rissmiller’s father lost his job. It was during his high-school years that the family had to sell their house and move into an apartment.

“I also saw my mom having to spend much more emotional energy on how were we going to pay the bills than on getting better,” says Rissmiller. He laments that the healthcare system is still not set up to care for patients and their family members during through their journey through that system.

Awareness of those difficulties drives Rissmiller to pursue evidence-based approaches to care.

For example, he led Atrium Health’s efforts to transform the use of blood transfusions. In 2016 (the latest year for which results are available), the health system transfused 104 units per 1,000 patient encounters; that’s down from 221 units per 1,000 patient encounters, according to a spokesperson. Cost savings in 2016 as a result of these efforts were $773,000.

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, blood transfusion is one of the top overused procedures in U.S. hospitals. 

, a unit of blood costs between $200 and $300, in addition to storage and processing costs and hospital fees. Cardiac overload (severe shortness of breath due to overloading the heart with fluid), infections, and lung injury are risks associated with blood transfusions.

Engaging physicians in reviewing the research and “believing in it” is vital. Just as important, according to Rissmiller, is getting physicians to “own” the initiative. That means physicians across the health system drive the initiative, instead of it being a “top-down approach.”

In his role as physician-leader at Atrium Health, Rissmiller is responsible for the surgical, primary-care, adult acute-care divisions, in addition to the health system’s behavioral health service line.

It’s his personal relationships with patients-just being present “with a patient who’s really afraid”-that “keep me going from a clinical standpoint,” says Rissmiller.

But encouraging employees to share that level of compassion and empathy can be challenging, especially in a large health system that includes hundreds of care locations.

“Just treating the disease is not enough. You need to engage the patient emotionally and find out about their life outside the hospital.”

He cites one example of a terminally-ill patient’s care team. The patient’s daughter was getting married, and he really wanted to see the wedding; still, the patient’s care team knew he wouldn’t make it to the wedding day.

To support the patient and his family, the nurses on his care team raced out to buy a cake and helped create a wedding ceremony in the patient’s hospital room. “That father was able to see his daughter get married from his bed. It was just an amazing event,” says Rissmiller, adding that the celebration came together spontaneously. He credits Eugene Woods, Atrium Health’s president and CEO, with encouraging all employees to “connect to purpose, which I absolutely love.”

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Being mindful about asking what’s going on in the home-such as for the patient with diabetes whose medications must be refrigerated and who can’t afford electricity-is tough, admits Rissmiller. While some physicians have these skills on an innate level, he says these skills can be taught.

Atrium Health offers role-playing-based training where a colleague will act as a patient and the doctor will interact with them and demonstrate their approach to care. The physician then receives real-time feedback and coaching on practical ways to develop a meaningful relationship with the patient. For example, that can include sitting at the bedside and really making eye contact, he adds.

When he’s not coaching physicians on his team or catching up with a patient, Rissmiller steals precious moments to strum on his guitar in his office. It’s been a “passion” since his teen years, and today he counts it as a great stress reliever. While Rissmiller considers Stevie Ray Vaughn his “all-time favorite guitarist,” he’s also a fan of B.B. King and Jimi Hendrix.

But if he can get a few days away from the office, his favorite way to spend time is with his wife and teenage children. He met his wife, a sports medicine physician at Atrium Health, during their residencies.

“We love to ocean fish,” says Rissmiller, and their favorite place to go fishing is Oak Island, one of North Carolina’s Barrier Islands. “It’s the only time I can get the kids off their cell phones,” he jokes.

After his mother’s journey with breast cancer, Scott Rissmiller discovered the deep desire to make an impact in others’ lives as a physician-leader.

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” from the CDC, an estimated 30.3 million Americans had diabetes in 2017, 7.2 million of which were undiagnosed. Approximately 5% had type 1 diabetes and the remaining 95% had type 2 diabetes. Over the last 20 years, the number of adults with diabetes has more than tripled, and the total direct and indirect estimated cost of diagnosed diabetes in the U.S. in 2012 was $245 billion.

“Diabetes is the highest traditional overall drug spend category for commercial, Medicare D, and Medicaid clients; and among all drug categories, only autoimmune has a higher drug spend,” says April Kunze, PharmD, senior director, clinical formulary development and trend management strategy, Prime Therapeutics.“Given the prevalence and the opportunities where diabetes care can go wrong, it can be an ideal area connected to outcomes-based contracts,” explains Mark Ginestro, a principal from 

. “The proper management of the condition can lead to major savings in overall medical costs.”

While there are some exciting promises in the pipeline, recent activity has cast doubts on that pipeline’s future. The FDA recently denied approval for the investigational drug Zynquista (sotagliflozin, Sanofi and Lexicon Pharmaceuticals) for type 1 diabetes.

Zynquista works by inhibiting both sodium-glucose cotransporter 2 (SGLT2), a transporter responsible for most of the glucose reabsorption performed by the kidney, and sodium-glucose cotransporter 1 (SGLT1), a transporter responsible for glucose and galactose absorption in the gastrointestinal tract.

The agency issued a Complete Response Letter (CRL) in March, following an eight to eight vote by the FDA’s advisory committee in January in favor of the drug’s benefits outweighing its risks.

“Given the advisory committee’s vote it is not entirely surprising that the FDA has issued a CRL for the Zynquista New Drug Application (NDA),” Kunze says. “Other SGLT2 inhibitors are being studied for use in type 1 diabetes. Currently, SGLT2 inhibitors are approved for the treatment of type 2 diabetes.”

Farxiga (dapagliflozin, AstraZeneca), one of the SGLT2 inhibitors currently approved for type 2 diabetes, was recently approved for type 1 in Europe and is currently undergoing studies in the U.S.-but Zynquista’s rejection has cast doubts on its future in the United States.

SGLT2 inhibitor manufacturers are also studying overall health outcomes, such as major cardiac events and sub-populations within diabetic patients, including those with chronic kidney disease or heart failure, to show potential benefit and expand labeled indications, according to Kunze.

Technology also has an important role to play, with wearable devices, such as continuous glucose monitors (CGMs) that aid in the diagnosis, treatment, and self-management of diabetes. Ginestro also says that medical device makers have introduced different variations of the “artificial pancreas,” an automated insulin pump with a CGM for management of patients with type 1 diabetes.

As far as additional tech innovations beyond the artificial pancreas, more digital tools are being introduced to help with the diagnosis, management, and treatment of diabetes.

“That can come from patient education materials being tied to smartphones, which can help in preventive care for pre-diabetes or helping patients manage the condition,” says Ginestro. “Another opportunity is tied to using tech to connect the doctor or patient to warn of elevated A1c levels or blood sugar readings to engage a patient to prevent a trip to the emergency room. The use of predictive analytics can also be applied to stratify patients by risk so the ones most vulnerable to repeat hospitalizations can get the help they need.”

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With remote patient monitoring now being reimbursed by CMS, Ginestro expects more players to emerge in proactive health management.

“We expect to see more type 2 diabetes patients opting for use of CGMs and other monitoring devices,” says Ginestro. “We can even foresee the broader consumer community using CGMs when they may be deemed pre-diabetic or even for those who are simply health-conscious consumers.”

The demographic of tens of millions of pre-diabetics and the obesity epidemic mean there will be no shortage of patients, according to Ginestro. “Medications are aimed at making diabetes management easier with longer acting medications and technology is helping with the management of these conditions and addressing unmet medical needs,” he says.

“Given the increasing drug trend and the variety of medications available, pharmacy benefit managers will be looking closely at preferred product opportunities to help manage spend,” says Kunze. “In addition, payers will be looking for the real-world experience to match the clinical trial outcomes.”

, is a staff pharmacist at Southwest General Health Center, Middleburg Heights, Ohio.

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With readmission rates on the line due to the ACA’s 2012 Hospital Readmission Reduction Program (HRRP)-which imposes penalties for higher-than-expected risk-standardized, 30-day unplanned readmission rates for six conditions-hospitals would be remiss if they didn’t establish an effective program to improve their measures.

) estimates that 12% of readmissions are potentially avoidable. Preventing even 10% of them could save Medicare $1 billion.

As pharmacists move farther away from their traditional role of only dispensing medications and accept responsibility for medication therapy management, hospitals are leveraging their expertise and placing them at the forefront of readmission reduction programs.

Role of pharmacists in readmissions programs

Eric Maroyka, PharmD, director, Center for Pharmacy Practice Advancement, 

, believes that pharmacists could play many roles in readmissions programs:

Conducting full medication reconciliation from hospital admission through discharge.

Offering recommendations, such as eliminating unnecessary or harmful medications, optimizing dosing, and suggesting alternative therapies to a medical team.

Making changes independently to medication therapy based on practice scope and collaborative practice agreements.

Assisting with care coordination and patient navigation near the time of discharge, providing patient education, and scheduling follow-up visits for medication management services.

Coordinating with pharmaceutical assistance programs, insurance carriers, and community or outpatient pharmacies to access and afford medications.

“An interprofessional and complementary approach using the pharmacist as the medication expert will add a necessary dimension to ensure an experience every patient deserves to improve access, cost, quality, and overall interprofessional team resilience,” Maroyka says.

While he has pinpointed the extensive role of pharmacists in readmission reduction programs, Maroyka is well aware of the challenges of such endeavors.

“Electronic health record interoperability remains a significant barrier across patient care settings,” he says. “This contributes to communication breakdowns and making less-informed decisions about patient care when accessing disparate data systems with incomplete or incorrect patient information.

“In addition, it is necessary to ensure staff competency enabling the pharmacy to have the capability and capacity to consistently support interprofessional care transition efforts across a continuum of care,” Maroyka says.

, a not-for-profit healthcare system in Tampa, Florida, introduced its Pharmacy Transitions of Care Program (

) as a pilot in 2014, with two pharmacists in one of its 15 hospitals. The program has since grown to 23 pharmacists and has expanded to all its hospitals. It targets Medicare A and B beneficiaries with primary diagnoses of a CMS core measure who are discharged from a hospital to home or an assisted living setting.

Timothy L’Hommedieu, PharmD, director of pharmaceutical services, East Region, BayCare Health System, credits the healthcare industry’s shift to value-based care for the initiation of PTOC. 

“The program’s goal is to decrease 30-day hospital readmissions. With drug therapy as the best way to treat acute and chronic conditions, the program provides an opportunity for pharmacists to play a significant role in transitional care,” he says.

Participating pharmacists are specially trained in ambulatory and transitions of care and hired just for that role, L’Hommedieu says. They are board certified and/or have received residency training­.

Collaborating with inpatient and outpatient care teams-which include social workers, home care experts, and physicians-pharmacists conduct two patient visits after discharge and telephonic encounters within seven and at 21 days after discharge, providing comprehensive medication review, medication therapy management, and counseling.

They also evaluate patient clinical status, help identify and solve any problems with medications-side effects, wrong dose, or inappropriateness or ineffectiveness-and ensure patients understand their medications and can afford and access them.

“Clinical pharmacists have always assumed these responsibilities but not in the transitional setting. BayCare has specifically invested in them to provide these services,” L’Hommedieu says.

The health system conducted a study using data from September 2016 to May 2017, comparing 2,200 patients eligible for a readmission penalty enrolled in PTOC with a control group of 1,335. The readmission rates were 8.3% versus 23.7%, respectively. Pharmacists documented 13,855 interventions (including 1,503 contacts with members of the interdisciplinary team), delivered 175 medication assistance programs, and provided 12,177 counseling interventions.

The program demonstrated a 63% relative reduction in all-cause readmission rates during that time period.

Although L’Hommedieu says HRRP is not the primary reason for developing the program, he is aware that results are publicly reported and can influence which hospitals patients select. “The law serves as justification for our investment in the value-based PTOC, which serves as a support program offering optimal patient outcomes,” he says. “If we deliver best practices, we set our patients up for success, and we can reduce readmissions.”

He emphasizes the importance of the team-approach to reducing readmissions, but admits it isn't always easy to coordinate such a group and provide a seamless experience for patients.

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Dignity Health-Northridge Hospital Medical Center

’s chronic disease transitional care program involves a team of physicians, nurse practitioners, nurses, social workers, and pharmacists who collaborate with an inpatient care team. They provide clinical oversight and discharge planning for a chronic disease population during a hospital stay and for 30 to 90 days after discharge.

After discharge home or to a long-term care environment, the team provides clinical oversight to patients in conjunction with external community partners, such as home health agencies and local pharmacies, and focuses on patient safety, health, satisfaction, and mitigation of avoidable readmissions.

By using an interdisciplinary approach to care, pharmacists can reach out to other experts on the team to help develop an individualized care plan and assist in creating strategies to support positive patient outcomes, says Jasmen Esfandi, PharmD, clinical pharmacist for the program.

Northridge in Southern California initiated the program in 2015, as an enhancement to its palliative care program, spreading population health and care throughout the continuum of chronic disease.

“The objective is to address an aging population within the community, ensuring a safe and appropriate level of care for patients after discharge and promoting self-care management,” Esfandi says.

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The number of patients affected by the program has nearly doubled to 7,300 since its inception.

Through medication therapy management, pharmacists and nurse practitioners provide recommendations for changes in patient medication regimens based on diagnoses. Pharmacists also perform discharge medication reconciliation for patients returning home or transferring to one of Northridge’s skilled nursing facilities.

If discrepancies or errors in medications-incorrect doses, drug interactions-are found, physicians join pharmacists in resolving problems.

Pharmacists take an additional step by making home visits to help patients understand their medication, ensuring patients have access to their medications, can account for any missing drugs, and know how to administer them.

Like pharmacists in similar programs, Esfandi says data collection is one of her biggest challenges; prompting the hospital to engage data coordinators to collect measures that communicate productivity, efficiency, and positive outcomes of the program.

She also agrees with her colleagues that while HRRP has helped drive the transitional care program, presenting estimated Medicare penalty savings indicates the effectiveness and value of the program.

Northridge has experienced a yearly decrease in readmission rates of 10% over the previous year. Esfandi says these rates are aligned with California goals.

After a pilot targeting adult patients admitted to a cardiac care unit from 2010 to 2011, 

 in Philadelphia developed its Medication REACH (Reconciliation, Education, Access, Counseling, Healthy Patient at Home) intervention in 2012, with a single pharmacist.

Since that time, Einstein has incorporated transition of care services into existing clinical pharmacist roles. Pharmacists collaborate with physicians, residents, and nurse practitioners from admission through post-discharge. The center added two pharmacy technicians, one to complete medication reconciliation in the emergency room and one as a discharge liaison to facilitate access to medications at the time of discharge.

The primary goal is to reduce hospital readmissions by improving medication management in the hospital, home, and during transition from these settings.

, which appeared in the May 1, 2018 issue of 

American Journal of Health-System Pharmacists, 

evaluated whether REACH was feasible as part of routine care at a safety net hospital and could reduce hospital readmissions for Medicare fee-for-service.

Using a multifaceted approach, Einstein sought to Improve medication management through direct pharmacist involvement and multidisciplinary communication between pharmacists and a clinical team.

Pharmacist intervention included reconciling medications, patient-centered education, ensuring access to medication, and follow-up at patients’ homes.

The study compared 30-day readmissions in patients with full and partial intervention with those receiving standard care. The results indicated 9.8% unplanned readmissions for the managed group versus 20.4% for the control group.

“It is important to establish collaboration not just between pharmacists and a medical team but also with care managers, insurers, and community pharmacists,” says Mariel Shull, PharmD, pharmacy utilization management coordinator for NYU Langone and the dedicated pharmacist in the Einstein study and its coauthor.

She sees pharmacists as an ideal fit for their role in a transition of care program that demands continuous coordination because of its complexity. “Pharmacists are medication experts that can ensure access to medications, improve adherence, and monitor patients.

“It is important to measure impact to support expansion of services and advocate for resources, but efficient documentation is difficult or challenging in many existing electronic medical records,” says Shull, concurring with Esfandi.

The stakes have never been higher in reducing readmissions and hospitals are leveraging pharmacists’ expertise and putting them at the forefront of readmission reduction programs

Managed Healthcare Executive April 2019 Issue

Five Ways Diabetes Treatments are Changing

Four Ways Health Execs Can Engage Providers

Featured Exec Scott Rissmiller, MD: Chief Physician Executive at Atrium Health

Cost Challenges Ongoing with Diabetes Drugs

How Health Systems Use Pharmacists to Reduce Readmissions

Team Approach Offers Hope of Increasing Diabetes Treatment Compliance

3 New Approaches to Provide Individualized Diabetes Care

How Payers Are Keeping Specialty Drug Costs Down

The Future of the ACA

3 Novel Diabetes Treatments Improving Patient Care

How Technology is Addressing SDOH

11 Soft Skills Healthcare Executives Need to Succeed