Diabetes prevention services often fit within the existing operational structure of a pharmacy and allow the pharmacy to maximize its personnel and resources.
All participants discussed alignment with existing operational structure and function as an important factor for adoption of diabetes prevention programs. Participants
characterized such alignment across several subcategories within this theme, including legal, regulatory, and documentation issues; physical space; standardization and time; staffing; and technology. Some participants discussed strategies learned from their company’s experience offering diabetes management programs related to alignment of operational structure and function that were transferrable to their initiation of diabetes prevention programs. Legal, Regulatory, and Documentation Issues
Several independent and chain pharmacy participants mentioned legal, regulatory, and documentation issues. The most commonly cited legal and regulatory barriers included the lack of pharmacists’ provider status at the federal level, which affects reimbursement and
delivery of screenings. A mass merchant non-adopter said some of the bigger challenges are, “… enrollment and credentialing of pharmacists as the provider of the service, and then recognition of the pharmacist as the provider is a huge hurdle.” A few participants also cited complicated or non-existent CLIA-waivers for pharmacies in some states that prevent them from offering point-of-care tests, including blood glucose and A1C. For independent
pharmacy participants, the lack of a CLIA-waiver, meant that their pharmacy could not offer blood glucose or A1C testing. As one independent pharmacy participant said, “…we’re not approved for point-of-care testing, so we don’t [offer it]. No CLIA-waiver” in their state. However, for most chain pharmacy participants that cited this issue, it typically affected their business in one or a couple of states rather than all their pharmacies. By way of example, a mass merchant participant explained that pharmacists conduct most of their diabetes screenings; however, in some states where their company is challenged by CLIA-waivers, they instead bring in a company with lab professionals or look to other professionals beyond pharmacists to conduct the screenings.
Beyond legal and regulatory issues, some participants also discussed documentation and administrative barriers. For independent pharmacy participants that mentioned this issue, they discussed the complexity of building up the business side of their pharmacy and finding time or resources to tackle billing and reimbursement processes. One independent pharmacy participant said, “I don't have an accounting or a business background. I have more of the clinical knowledge. If I had somebody more in tune to the billing and reimbursement side it would be easier…” For grocery participants, the administrative barriers also related to billing and reimbursement primarily, but specifically tied to administering existing contracts with employer-based programs or payers. One grocery participant summarized concerns shared by
other grocery participants with contracts for reimbursement of services, “Then, the fact that pharmacists billing through our pharmacy. When you're going to bill something like that [e.g. screenings], it's a medical billing type thing, and getting providers of insurance, like getting a United Health or an Aetna, or something like that to pay for courses can be very problematic … Getting them [the insurance company] to put us into their billing [system] is like an Act of Congress sometimes to go through all the forms and things, and their systems aren't necessarily equipped to have pharmacists bill …”
A few chain pharmacy participants mentioned that their pharmacy prescription management systems contribute toward administrative and operational issues. For
participants that mentioned this issue, they noted the difference between delivering a service for free versus delivering a billable service. For instance, if a pharmacy offered blood glucose screenings for free, then that service may not be documented for a consumer’s profile within the pharmacy’s prescription management system. However, to bill for that glucose screening, then the pharmacy would need to have a documentation system that allowed them to process medical billing claims. A mass merchant participant explained that to provide a billable service, not just a screening, “… we need to be able to have records and manage, and reporting that someone's going to pay us for it.” A few chain pharmacy participants
mentioned that documentation of screenings in pharmacy systems as a billable service allows for more robust tracking and analysis of services delivered and consumer health outcomes.
Beyond concern about billable pharmacy services, several study participants expressed concern about enrolling and getting reimbursed as an MDPP supplier. One independent pharmacy participant said, “While they [Medicare] reimburse, it's a process to go through the accreditation. I believe it's a year you have to provide the program … That's
an investment up front for us to do. It's not really easy and clear cut and straight forward when it comes to navigating through that process. I don't have a lot of support staff to delegate those things to, and unfortunately I don't have the time myself with all my other responsibilities to navigate through all that right now.” A few participants expressed that they did not know what an MDPP supplier was before the interview and did not immediately realize that this type of payment through Medicare is unrelated to delivery of clinical
services, and, as such, is separate from issues related to a pharmacist’s provider status. A few participants had questions and concerns about the intervals at which MDPP reimbursement kicks in (e.g. Does Medicare wait a full year to reimburse MDPP suppliers or are suppliers reimbursed at intervals throughout the year-long program?). Most participants had a positive outlook about the possibility of becoming an MDPP supplier, but many felt navigating the process to become a supplier would be complex.
Physical Space
Many independent pharmacy participants discussed physical space as a barrier to offering diabetes prevention lifestyle change programs. For this subcategory, the smallest chain pharmacy with fewer than 20 stores had greater similarity to independent pharmacies than chain pharmacies. Most independent pharmacy adopters of lifestyle change programs conducted classes in a pharmacy consultation room or pharmacy waiting area. These participants said their class sizes had to be capped based upon their physical space.
Conversely, grocery participants had more options for space and could prioritize offering lifestyle change programs in specific stores with better space for hosting a class. All grocery participants reported adequate space to conduct lifestyle change programs mainly through meeting rooms or café space. One grocery participant mentioned that some of their
stores are equipped with classroom space that includes cooking stations for demonstration and teaching purposes. While all grocery participants said they had meeting space in select stores, some still viewed space as a barrier, “Well, there are physical barriers in that not all of our stores are equipped with meeting rooms that have no facilities for X number of people, so sometimes we have to be creative in where we're doing a class …” Some grocery
participants said pharmacy consultation rooms could be used for lifestyle change classes if no other space were available at a store.
Since most traditional chain pharmacies and mass merchants were non-adopters or former adopters of lifestyle change programs, they discussed physical space less often than independent pharmacy and grocery participants. However, a few independent and chain pharmacy participants mentioned trade-offs associated with space. For instance, if a lifestyle change program is held in a pharmacy consultation room for an hour, then during that time, a pharmacist may not be able to offer vaccinations or other clinical services.
Some independent pharmacy participants, and the chain pharmacy with fewer than 20 stores, identified creative space solutions by partnering with other organizations within their communities. A local chamber of commerce provided an independent pharmacy with free space to offer their lifestyle change program, while another independent pharmacy sought classroom space from their local health department, churches, and other community-based groups. When asked about expanding their company’s delivery of the National DPP lifestyle change program to additional locations, a traditional chain pharmacy participant said, “I'd like to but it's really challenging to find a meeting space that's consistent, that's easy for your patient …” An independent pharmacy, former adopter said they had to offer classes after hours in their pharmacy due to a lack of space, “which meant there was no revenue being
generated from the class period … I wish I had a mechanism to allow classes to be held during business hours, but I don't.” No other participants held classes during non-business hours.
Standardization and Time
Many participants discussed time in tandem with other alignment and reimbursement issues, but time also emerged as its own factor for adoption of diabetes prevention programs. Participants typically expressed time in context of their company’s workforce and making appropriate use of their employees. Many participants discussed pharmacy workflow, and the decision to remove a pharmacist or pharmacy technician out of the medication dispensing workflow at certain times to offer diabetes prevention programs.
Many participants described the decision to remove pharmacy staff from workflow as a trade-off that required careful consideration and planning. A traditional chain pharmacy non-adopter explained this decision process as follows, “Our work flow is designed to really generate large volumes of scripts in a very standard and high-quality, safe way. And so, we do offer pharmacy interventions, and we take our pharmacist out of work flow to have conversations with patients, but … we're really strategic … because there's only so much time that the pharmacist has to have these conversations and conduct these interventions.” A few participants discussed time in terms of consumer demand for services. Those participants said their company was willing, and did, pull pharmacy staff out of workflow to deliver diabetes prevention programs; however, they re-evaluate that choice if consumer demand is low enough that delivery of the service is no longer a productive use of the pharmacy staff’s time.
Given the premium placed on pharmacy workflow, several participants shared
deliberate efforts to maximize the time and capabilities of pharmacy staff. A few participants discussed the benefit of regularly scheduled screening events. One grocery participant said that for 10 years their company offered screenings inconsistently across their stores and then transitioned to offering them on a regularly scheduled interval, “… so there’s no question in the public’s mind about having to call and say, ‘Are you doing this? Are you not doing this?’ They can go to any of our stores at the same time. That's why we decided to standardize it and do it in all stores, train up enough people, so that we have the capability …” A few participants also recommended individual appointments or specific clinic/screening hours as one way to ensure the pharmacist has dedicated time to offer the screening and provide the patient with education.
Staffing
Most independent and chain pharmacy participants agreed that, beyond pharmacists, other staff can support or lead diabetes prevention programs. Most participants agreed that clinical and support staff should work at the top of their license to operate efficiently while providing optimal patient care services. While use of dieticians, support staff, pharmacy students, and residents where possible instead of a pharmacist is a cost-saving measure, most participants carefully considered how and when to utilize their valuable personnel resources, weighing quality and appropriateness, in addition to cost.
Dieticians
All grocery participants said their company uses dieticians to offer diabetes prevention strategies; independent, traditional chain, and mass merchant pharmacy
the lifestyle coaches leading the classes for their company’s lifestyle change program, while another grocery participant stated that nutrition and pharmacy technicians lead their classes, supported by pharmacists and dieticians. Regardless of what type of staff member led the classes, most grocery participants said both pharmacy and dietician staff supported delivery of diabetes prevention programs. One grocery participant credited their company’s lead dietician with bringing forth the idea and subsequently launching the National DPP lifestyle change program for the company. Another grocery participant said about their launch of the National DPP lifestyle change program, “So, just because we have access to dieticians, I would strongly recommend that dieticians play a role, if possible and if they're available.” All grocery participants agreed that having dieticians on staff at their companies was
advantageous for diabetes prevention and should be leveraged for delivery of lifestyle change programs. A few participants mentioned that dieticians do not have the same workflow constraints as pharmacists, which allows them to be easily incorporated into a lifestyle change program.
Pharmacy Students and Residents
Independent and chain pharmacy participants spoke positively about the role of pharmacy interns and residents in diabetes prevention. Some participants expressed regret that they did not have more students or residents, as they found their support to be invaluable for diabetes prevention programs. Participants without access to pharmacy students or
residents often spoke fondly of such an opportunity. One independent pharmacy participant said, “We don't currently have a resident. If I did have a resident, absolutely, that [the National DPP] would be one of the things that I would very adamantly have them
pharmacy participant that does not deliver diabetes prevention programs said, “It allows us to give our technicians, our pharmacy interns meaningful experiences, and it just makes so much sense. And it's obviously easier too, to pull a technician or an intern out of work flow, so we love those types of opportunities and we do them today. So, we would be very, very open to that kind of model.”
Several participants said pharmacy residents had a strong role in their company’s initiation or continued delivery of a lifestyle change program. A few participants said that residents served as lifestyle coaches. One grocery store participant who described extensive expansion of their company’s delivery of the National DPP lifestyle change program credited a small-scale resident project from more than 10 years ago as the catalyst the led to their company’s adoption. An independent pharmacy shared the central of a role their resident for their offering of the National DPP lifestyle change program, “Now, our resident pharmacist … it's been [the] residency project to get everything turned in [to CDC], to be keeping up with patient logs and patient visits and things like that. He has very good familiarity with it. My personal familiarity with it is not quite as strong as his is.” Independent pharmacy participants expressed greater reliance on their pharmacy residents to deliver the National DPP lifestyle change program.
Pharmacy Technicians
Several participants agreed that pharmacy technicians could support diabetes prevention programs, but the extent of that support varied from administrative roles to delivering screenings to serving as lifestyle coaches. A few participants mentioned that when launching a lifestyle change program, they trained pharmacists as lifestyle coaches, but could see transferring some or all that responsibility to pharmacy technicians in the future. A
grocery participant said, “… right now we had one pharmacist trained [as a lifestyle coach]. But for me, the DPP is not going to be a pharmacist. It's just, I'd rather have it be a trained technician level … I see this being facilitated at least on the DPP side, being facilitated by a highly-trained technician, with pharmacist intervention as needed.”
Technology
Some participants discussed the current and future role of technology in diabetes prevention programs. Some chain pharmacy participants, and a few independent pharmacy participants, discussed the potential for online or virtual delivery of the National DPP lifestyle change program. One traditional chain pharmacy former adopter said, “I think we just have to look to see if there are improvements that we can make in leveraging today's technology to make those programs a little bit more effective.” One grocery participant mentioned their company’s proactive effort to develop a, “digital and face-to-face option [for the National DPP], and highly encouraging a combination option. Initial visit in-person and then customize the program based on their needs. We are partnering with [third-party vendor] to offer the digital component of the program, which will be available soon. One-on- one and then moving into online program with group support.” This participant described the most advanced effort to transition from in-person to mostly virtual delivery of the National DPP lifestyle change program.
Most participants that discussed technology shared their perspectives on the potential or future role of technology, but their company had not implemented such strategies. Only one participant that mentioned virtual delivery of a lifestyle change program had a negative view towards it, “And if you really want to get into quality pharmacy care by the pharmacist or by someone in the pharmacy, I don't care what anybody says, face-to-face still works the
best. You know, you can't develop a personal relationship on the internet.” Some participants were not aware that lifestyle change programs can be offered virtually, but when asked about it, generally were supportive of the concept.
Theme 4: Relative and Competitive Advantage
A clearly articulated advantage against competition with alignment of values is key to a pharmacy’s adoption of diabetes prevention services.
The principal investigator asked study participants about the advantages and disadvantages associated with offering diabetes prevention programs. A few participants mentioned that their competitors had started offering diabetes preventions strategies, so they too considered adoption to stay competitive, but other advantages emerged as more
important. Many independent and chain pharmacy participants mentioned their primary advantage as increased customer loyalty. By offering diabetes prevention programs, these participants felt they established increased trust and good will with their customers. An independent pharmacy participant said patients feel valued and heard, and as a result, “… they can leave having learned about diabetes, and physically how to prevent it. And that, ultimately, promotes customer loyalty, which would then promote pharmacy shopping. It's a domino effect.” Participants said increased loyalty subsequently had the potential to increase store and pharmacy sales, and some said their sales had increased because of their diabetes prevention programs.
Several participants said that because they delivered diabetes prevention programs,