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October 2016, Vol 4, No 10 - The First Word
Donald J. Dietz, RPh, MS

The pharmacy profession has evolved from an era long ago, when most prescription drugs were compounded, to today, when the vast majority of prescribed medications are tablets, capsules, or prepackaged drugs made by pharmaceutical manufacturers under US Food and Drug Administration approval. To improve efficiency and accuracy, and to control costs, pharmacies have implemented various levels of technology and automation, which free up time for pharmacists to perform additional activities. In many pharmacy environments, this time is used to process more prescriptions, which is often the prudent and most profitable option.

Other uses of pharmacists’ skills include medication therapy management (MTM) and providing immunizations to patients. Over the past decade, retail pharmacy has done an excellent job integrating immunizations into their pharmacy workflow, providing patients with a no-appointment, convenient immunization service. Long gone are the “flu shot” days when a third party was brought into the pharmacy to immunize patients.

MTM is another nondispensing, pharmacist-provided activity. Currently, uptake of MTM programs at retail pharmacies has been slower than hoped by many pharmacy leaders, for a variety of reasons, including multiple MTM platforms, systems external to the pharmacy dispensing system, reimbursement levels that are less profitable than prescription dispensing, and a lack of MTM opportunities at each pharmacy to become efficient.

As additional technology and automation advances occur, I wonder what new, nondispensing services pharmacists can provide that are needed by, and of value to, patients and our healthcare system.

Diabetes Screening the New Opportunity for Pharmacies?

Recently, I became aware of updated screening guidelines for abnormal blood glucose (ie, prediabetes) and for type 2 diabetes from the US Preventive Services Task Force (USPSTF).1 The USPSTF recommends that clinicians screen for abnormal blood glucose and type 2 diabetes in individuals aged 40 to 70 years who do not have symptoms of diabetes and are overweight or obese. Furthermore, patients with a family history of diabetes, or those who are of African American, Hispanic or Latino, American Indian, Asian American, or Pacific Islander ethnic groups may be at an increased risk for diabetes, and are therefore also eligible for this screening. In addition, the USPSTF recommends that clinicians offer or refer patients who have prediabetes to intensive behavioral counseling interventions to encourage a healthy diet and physical activity.

Approximately 3 times as many adults are eligible for this screening under the new USPSTF recommendations compared with those eligible according to the previous recommendations from 2008.2 This new, comprehensive guideline has the potential to detect most cases of undiagnosed prediabetes and diabetes, especially among individuals from racial and ethnic minorities who are disproportionally affected by the disease. Perhaps this guideline presents the new opportunity for pharmacy and retail clinics inside of pharmacies.

Beginning in 2017, private health plans are required to cover screenings for prediabetes and diabetes at no cost to patients.2 As of January 1, 2018, Medicare will begin to cover diabetes prevention programs for eligible beneficiaries who are at risk for type 2 diabetes.

Pharmacists and retail clinic personnel inside retail pharmacies are in a unique position to provide these screening services. We are the most accessible healthcare practitioners. Pharmacists have access to medication profiles, and can identify patients who are receiving antidiabetes medication as a means of identifying family members who may be at risk for the disease. We can also help identify other patient populations who use our pharmacy and are at an increased risk for diabetes.

The most straightforward approach is for pharmacies with retail clinics operating within their walls. Referrals to the retail clinic for a blood glucose screening, which may include hemoglobin A1c and fasting blood glucose, are an excellent way for the pharmacy and retail clinic to work together. For pharmacies without a retail clinic within their walls, it is estimated that approximately 20% of all pharmacies have a Clinical Laboratory Improvement Amendment (CLIA) waiver allowing them to perform diagnostic and screening tests.3

How big is this opportunity? The Diabetes Advocacy Alliance reports that approximately 86 million Americans have prediabetes, and more than 75 million of them do not know they have the condition.2 The Diabetes Advocacy Alliance also reports that approximately 30 million Americans have diabetes, with 8 million of them undiagnosed.2

Barriers to Diabetes Screenings

What barriers exist for pharmacists to provide these services? First is the ability to draw blood samples in pharmacies in your state, and having the proper CLIA waivers in place: this is the largest barrier to >80% of pharmacies today.3

Second is pharmacies’ abilities to bill for community pharmacy−based point-of-care testing. Access to provider networks to bill for these services is a barrier today. Third are legal considerations involving federal and state laws. Collaborative practice agreements may need to be put in place. Finally, evaluating the reimbursements available for these services compared with the opportunity cost for pharmacists’ time is a key consideration.

Yes, these barriers are daunting; so were the barriers to pharmacist-provided immunizations 20 years ago. Pharmacy needs to seek out the clinical, nondispensing activities to augment the dispensing of prescriptions. Diabetes screening is one possibility with great potential. Other possibilities include cardiac examinations with auscultation, and spirometry for patients at risk for chronic obstructive pulmonary disease or asthma.

Now is the time to begin thinking about the next nondispensing, clinical service that pharmacists can provide. I hope this article will increase awareness and spur positive activity toward our next nondispensing, pharmacist-provided service.




References

  1. US Preventive Services Task Force. Final recommendation statement: abnormal blood glucose and type 2 diabetes mellitus: screening. September 2016. www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed October 19, 2016.
  2. Diabetes Advocacy Alliance. More of your patients are now eligible for free diabetes screening and prevention programs. August 2016. www.diabetesadvocacyalliance.org/pdf/DAA_HCP_Screening_and_Prevention.pdf. Accessed October 19, 2016.
  3. Next Generation Dx Summit. Leveraging pharmacies for rapid diagnostics. August 2016. www.nextgenerationdx.com/pharmacy-diagnostics. Accessed October 19, 2016.
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