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November is National Diabetes Month. In this conversation, hosted by PCMA’s Angela Banks, we discuss the work that PBMs are currently doing to help millions of patients with diabetes manage their care. Express Scripts’ Chief Medical Officer Dr. Christine Gilroy joins us as our guest.
JC Scott, President & CEO of the Pharmaceutical Care Management Association, discusses the latest trends, public policy developments, and political challenges impacting drug pricing and healthcare.
You'll hear the nation's top thought leaders, policy experts, and political analysts on topics like how employers, unions, and others use Pharmacy Benefit Managers (PBMs) to drive value for their members in the face of growing healthcare costs. You'll also learn about advancements in gene therapy, biologics, other cutting edge therapies, and the patient benefits and cost challenges that come with them.
The Pharmacy Benefit will also analyze the latest news from inside the industry and give you an educated perspective on where things currently stand and where we think they're headed.
Angela Banks (00:08):
Welcome to the Pharmacy Benefit, a podcast that highlights the role of PBMs in serving millions of patients and consumers throughout the country. I am Angela Banks.
(00:18):
November is Diabetes Awareness Month, and if you've listened to this show before, you know that we focus heavily on how PBMs provide better healthcare outcomes, and that is no exception when it comes to the millions of people nationwide who live with diabetes and manage it on a daily basis. Let's look at some quick numbers. About 37.5 million Americans have diabetes. That's roughly one in 10 people in this country, according to the CDC. It is the seventh leading cause of death in the United States. And in 2017, the cost of diagnosed diabetes was estimated at $327 billion. People living with diabetes are at an increased risk for many serious health problems. In addition to the negative health impacts, diabetes is an expensive condition to manage. In 2017, medical diabetes care costs the average person living with diabetes $9,601.
(01:15):
PBMs work to help alleviate the high drug costs that may arise with diabetes and also implement medication adherence programs and care management programs to help patients with chronic disease stick to their prescription regimens. These programs improve clinical outcomes and often increase prescription volume and expenditures. Joining me today to talk about all of this is Dr. Christine Gilroy. She is the Chief Medical Officer at Express Scripts, where she leads the company's clinical efforts to improve health outcomes and increase affordability for clients and members. Dr. Gilroy works closely with clients to provide clinical guidance on critical plan design decisions and solutions to address healthcare's biggest challenges, one of which is diabetes. She has more than 25 years of clinical experience and has certainly seen many changes in this space over the years.
(02:06):
Dr. Gilroy, welcome to the Pharmacy Benefit.
Dr. Christine Gilroy (02:09):
Thanks Angela so much for having me today.
Angela Banks (02:11):
We really appreciate you joining. Let's start by letting our listeners learn a little more about you. How did you get your start and why did you choose a career in this field?
Dr. Christine Gilroy (02:21):
For me, I am an internal medicine doctor by training. And obviously, diabetes made up a large part of my day-to-day practice when I was taking care of individuals with diabetes. And when I was doing my training, I had an opportunity to do a fellowship in health services research, which is really looking at how evidence goes from being in a clinical trial to actually out into the real world. And that real world evidence experience really sparked me to the fact of the number of barriers that exist in getting individuals to reap the benefit from treatments that are out there for common diseases like diabetes, and also the interplay between diabetes and what people actually end up having injury and death from in diabetes, which is more cardiovascular disease and stroke than direct complications of high blood sugar. With all of that, it became a focus in my practice, not just to work on the individual that I was taking care of, but actually also to look towards how I could participate in changing systems of care to make it easier for people to get good care for their diabetes wherever they were at.
(03:39):
I went to work for federal and high risk pools. We had grants to be able to make it easier for people to get care, especially in rural and frontier areas of the United States. And then I went to work for a health plan that served low-income people on Affordable Care Act and Medicare Advantage plans. One of the things that really struck me was that the pharmacy benefit was the place that touched the most people and made the biggest impact and whether an individual felt that they had the capacity to manage their diabetes process. And so, when I was looking for my next opportunity, one of the areas that I really wanted to focus was on working with a pharmacy and pharmacy benefit management company because I really felt that I could make an impact in helping to design clinical programs that would create more meaningful paths to care for more patients nationwide.
Angela Banks (04:33):
That's great. I'm sure that well-rounded experience serves patients and Express Scripts really well. Appreciate you sharing that. How is the PBM industry as a whole helping to handle the challenges associated with having so many people living with this chronic health problem?
Dr. Christine Gilroy (04:49):
Great question, especially as traditional pathways to care become more difficult to access for more people. Thinking about that first point of access for an individual who's had a diagnosis, how is that individual able to have a medication selected for them, go to a pharmacy to pick it up and actually have an affordable price at the point that they're trying to access the medication? And then actually, even looking at ways that pharmacists and other non-physician providers can work to help with that management pathway in between the visits that they have with their primary care provider or with their diabetes specialist.
(05:32):
So one of the things that we're looking at is how individuals like pharmacists or even pharmacy techs can help us to identify those individuals who are having a hard time with taking their medication, helping us to outreach them or their physician, and help to understand barriers that they may experience in accessing the medication. And then, for a number of our clients in rural areas where primary care is particularly difficult to access, we're actually embedding clinical pharmacists in the workplace so that people can get advice on how to manage their diabetes while they're at work.
(06:10):
We have one partnership with Cummings where we have three pharmacists in their workplaces across the United States, and they've really seen about a one to 1.5% decrease in HbA1c or better diabetes management just through that constant connection with a clinical pharmacist who really understands where the patient is coming from. There's an opportunity for us to look across many different sites to figure out how to serve patients where they're at without that added barrier of having to try to reach a primary care physician. How can we all jump in to support the patient where they're at for better outcomes?
Angela Banks (06:48):
Excellent. Meeting patients where they are, appreciate that. There is a keen focus on how PBMs bring value. A recent study noted that PBM services generate 148 billion in savings annually, and that is certainly important, but I want to talk a bit about adherence programs because very few might be aware of what PBMs are doing when it comes to diabetes management. Tell us a little about what Express Scripts is currently doing.
Dr. Christine Gilroy (07:15):
Express Scripts historically has a group that supports specialty drug management for people with complex chronic conditions. They're called therapeutic resource centers. And they're staffed by clinical pharmacists and other healthcare providers to support individuals with chronic disease, like lupus or rheumatoid arthritis. We saw the need to stand up a similar program for all of our members with diabetes, not because the drugs were as complex, not because the access to those drugs was more constrained through specialty pharmacy access, but because that interdisciplinary team and the need to identify and meet patients where they're at was so large that we determined that that was a really important place for us to begin to support our patients. So our data and analytics team are combing through the prescriptions that people receive that identify that they likely have diabetes, and then that information creates flags that go to the diabetes care value resource center. And those pharmacists, and techs, and sometimes even nurses, are then using that information to outreach to our members with diabetes.
(08:34):
One of the areas we're really looking to expand is that we're seeing that patients, even those individuals who are adherent to their diabetes medication, are often not adherent to their blood pressure medication or their statin medication. And we are really looking at this as a three-legged stool of how to support an individual with diabetes. Again, is not the blood sugar that causes the next injury to the patient, the hospital admission or cost, it's actually the combination of managing the diabetes with the blood pressure and preventing a heart attack or a stroke. So we're starting to expand our gaze just from the diabetes medication to, are they taking the diabetes medication with the blood pressure medication and the cholesterol medication to make sure that we're lowering the total risk for that individual across their lifespan?
Angela Banks (09:29):
That's really interesting. It sounds like you're using some predictive analytics to find potential areas of concern and acting on that.
Dr. Christine Gilroy (09:38):
I think not as much predictive analytics as it is really looking at the patient's data holistically, right? So not just the diabetes, but really looking out to start incorporating information that we know, not from predictive learning or machine learning, but really, from other good epidemiologic data, points us to the next risk for that individual and how do we mitigate that risk.
Angela Banks (10:03):
If there is a diabetic patient who uses Express Scripts for one or several medications, walk us through what that PBM does to monitor them and ultimately take care of them.
Dr. Christine Gilroy (10:13):
So as I mentioned with the Diabetes Therapeutic Resource Center, we're looking at those prescriptions on a continual basis. And we have that Diabetes Therapeutic Resource Center available for individuals to call into as well. If they have questions about their diabetes care, if they access their pharmacy benefit management, they can say, "I have questions about my diabetes," and get connected to those expert resources. There. We're also continuing to look at medications that are particularly vital for the management of diabetes and making sure that we are leveraging our relationships across the pharmaceutical manufacturer environment to keep those medications low price and available. That was the impetus behind our insulin caps that we put into place a number of years ago. We think those are going to be more important. Again, as we look at the post-COVID environment, where we know that the COVID virus has a tendency to attack the pancreas specifically, and so, we are already seeing an increase in number of individuals with type two diabetes who are actually moving onto insulin therapy likely as a result of a COVID infection. Again, we're looking more closely at that data. We expect to see that pattern given other COVID-like viruses and the emerging pattern appears to be there.
(11:38):
The other opportunity that we have is that we have population health nurses and diabetes educators that can be accessed through additional programs. So we do have population health support programs. We have something called the digital health formulary. These are add-ons, but a large number of our clients elect to add these services on to the basic diabetes care that we do in order to expand access to care for their employees and members, and also to make sure that they're really deriving the benefit of the medications. Those medications are really the early warning system for diabetes and spend in your environment. And outreaching to those individuals early on as we identify them, creates a really nice pathway through to improved management and improved care through extra programs. Health Connect 360, the Digital Health Formulary, and a number of others.
Angela Banks (12:34):
Thank you. It sounds like we have some actionable transparency with physicians being able to see exactly what the formulary is at the point of prescribing and the available medications and at what price point.
Dr. Christine Gilroy (12:49):
Yes. We've been working on real time prescribing information. So more than the Surescripts input to an epic environment, we've really been working on building out real time prescribing information. Obviously, the provider's home EMR is one of the barriers to that adoption. And in areas where we don't have the ability to support those feeds into their EMR, we're actually going back and just using pharmacists to outreach the providers and educate them about what's available or more affordable for their patients. But the best for us to do is to make sure that that makes it into their prescribing environment and really expanding on information that's available through a portal like Surescripts to that real time prescribing information.
Angela Banks (13:36):
And then, I see that you are bringing the medication to the patients, meeting them where they are to also increase accessibility.
Dr. Christine Gilroy (13:42):
It's been important to recognize the challenges that people face in different parts of the country. Certainly, this is something we've been talking about in terms of social disparities of health for a while, and in looking at our own health equity index, it was surprising to us. We actually did not expect. We thought that getting to that Smart 90 prescription where we were really extending the number of days, was helping to resolve those barriers to access for people. We were not acknowledging how much of a barrier transportation was for a number of our individuals. And that direct experience with employers where they said, "Not only do we not have a primary care provider in our community, we don't have a pharmacy either," helped us to understand how important it was to make that connection back again to home delivery.
Angela Banks (14:34):
I'm sure there are many, many people out there who really appreciate that. A good diabetes management actually lowers cost as well. Correct?
Dr. Christine Gilroy (14:45):
Yes. In working in the health insurance environment prior to being Express Scripts, the pharmacy spend is one component of it, and the medical spend obviously is the second component. And trying to knit those together and make sure that even a slight increase in spend on the pharmacy side of the benefit can actually really defray additional costs on the medical side of the benefit is very important to help our clients understand. And so, part of our diabetes care value program is really targeted at looking at that longitudinal aspect of spend. So looking at the pharmacy spend, looking at how the pharmacy spend is tied to total management of that patient's risk, bringing in the hypertension, bringing in the cholesterol, and then also looking at whether or not that individual is also going to emergency rooms or being admitted to the hospital and including that in our guarantees and commitments back to our clients.
(15:48):
One of the things that we see as an opportunity is that when somebody starts on a medication, particularly some of the higher cost medication for diabetes, those medications also come with a worse side effect profile. And so, we're working to create guarantees where when an individual starts on one of those higher cost medications, if they don't continue on it, we're able to actually give reimbursement or a refund back to the payer, whether it's the health insurance company that we're working with or whether it's the employer that's sponsoring the health insurance plan. We want to make sure that when somebody tries a higher cost medication for more complex diabetes, that if they don't tolerate that medication, the payer's able to recoup that risk on that individual, that it's not leading to worse diabetes control, or frankly, more emergency room visits or admissions.
Angela Banks (16:47):
Is that being done through value-based arrangements?
Dr. Christine Gilroy (16:50):
It is being done through value-based arrangements, absolutely. It's one of the things I'm really excited about. I think another area that we don't talk about enough in diabetes management is the intersection of diabetes and behavioral health complications. And so, we're looking to launch a coordinated program from Express Scripts to PBM with our other partners in Evernorth in the behavioral health arm, to be able to look at those individuals and help to manage their distress, their anxiety, and even sometimes depression that's tied to that diabetes diagnosis. So we also are able to point that where most diabetes patients cost $9,000 per year in total, if you just combine diabetes with simple depression, most of those individuals cost upwards of 21, $22,000 per year. It's directly tied to difficulties that they have with managing adherence to their medication, with the anxiety that might actually end up driving an additional emergency room visit, or even not taking the medication the way it's prescribed, so an adherence issue leading to a hospital admission. So that's one of the next steps that we're looking in taking at addressing the full aspect of care for diabetes.
Angela Banks (18:11):
Speaking of next steps, as we look toward the future, recognizing diabetes as a national issue unlikely to be resolved in the near term, what more needs to be done? What are the areas that we as a PBM industry need to focus on in the coming years when it comes to supporting diabetic patients?
Dr. Christine Gilroy (18:29):
One of the things that I would point to is the perception of diabetes as being a chronic disease that starts in your 40s and 50s. The data actually extends well beyond that. So when we look at a increase in the prevalence and incidents of diabetes right now, we need to trace that back to when that individual with diabetes was actually in utero. We know that what a mom is eating or how stressed she is can actually significantly increase the risk for developing diabetes 40 years later. We know that when people go through puberty, their insulin levels go up. And for those individuals with who will develop type two diabetes, they just don't go down again. And that's multifactorial. It's partly diet. It's a lack of exercise. It's stress. It's many other things. And so, these things are all really building together. And if I look out 30 to 40 years in the future, we're really looking at what I would consider to be catastrophic increases in risk of diabetes across our population.
(19:42):
I think that we really need to think about our environment and our communities. And things that can be done in the environment, in the community is to help mitigate and prevent diabetes now for the coming generations. One of the things that's been really interesting to me in thinking about what the PBM can do is that we've actually had an increase in the number of our clients who are wanting to talk to us about how can we treat food as medicine, how can we partner with them in thinking about the diet that they have access to, or even what's delivered to their home as supporting their diabetes equally as importantly as the medicines that we're delivering to their home. It's something we've only just begun exploring, but I do think there's a very interesting and natural allegiance in thinking about food as being just one more component of everything that needs to be done in managing an individual with diabetes.
Angela Banks (20:43):
Is there also a component around other lifestyle changes that could impact diabetes?
Dr. Christine Gilroy (20:51):
Absolutely. I think that there are many lifestyle changes that we can help people to make. I think that opportunities to partner around wearables and provide feedback on physical activity. Exercise is often a step too far for many of our diabetic patients to consider. But when we just provide feedback on physical activity and then ask them questions about it. It looks like you were sitting still for seven hours during the day yesterday. Is there advice that we can provide around that?
(21:25):
We do connect our clients with opportunities for coaching programs, diabetic coaching programs that address pre-diabetes, physical activity, and then coaching around diet through our digital health formulary. But certainly, hearing an appetite to expand those programs, especially from our employer clients. They're really looking also at this avalanche of diabetes and their future employees and want to know how to get ahead of it now.
Angela Banks (21:54):
Thank you, Dr. Gilroy, for this very informative conversation. I appreciate it. And thanks to all of you for listening. If you haven't already done so, please consider subscribing to the Pharmacy Benefit and downloading all of our podcast episodes. You can do that on Google Podcasts, Apple Podcasts, Spotify, or wherever you find your favorite podcasts. I am Angela Banks. Thanks for joining.