Pushing Diabetes Profitability

Test strips and meters bring diabetes patients in the door. To drive profitability, you need to give patients more help once they're inside.

• By Holly J. Wagner
• Dec 01, 2019

Diabetes meters and test strips are well known to DME pharmacies as products that don’t pay; you stock them to keep diabetic customers from going somewhere else. However, don’t write off the business. Those break-even and loss-leader items can open the door to a diabetes management program that helps improve your customers’ health and your bottom line.

What if, instead of thinking of meters and test strips as a necessary concession, you started to look at them like the opera gloves at a burlesque show: they may bring people in, but if that’s all you have, the audience will be disappointed once they’re off and look for the juicy bits somewhere else. If you want to keep those clients, you have to show them more when you pull back the curtain.

Turning your diabetes population into a predictable profit center takes a bit of work and training. It might mean offering new services, changing your DME product mix and merchandising, updating your business software or practices, and even the way you allocate time and floor space at your business — that depends on how far you want to go. It’s a big undertaking that offers rewards if you do it well.

Keep in mind that the typical diabetes patient has at least five other prescriptions unrelated to diabetes, sometimes many more. They may include antihypertensive, antihyperlipidemic, mental health and antihyperglycemic drugs. But even that’s not all they need, and making yourself a one-stop-shop is convenient for them, helps improve outcomes and increases your revenue.

IS IT WORTH THE COST AND EFFORT?

First, you have to decide if your client list warrants the effort of becoming a “diabetes hub.” How many of your regular clients are on diabetes medication? Are you in a market with a high percentage of diabetes patients? Is your business near a dialysis center?

The statistics say at least one of those things is likely. The Centers for Disease Control reports that 30.3 million people in the United States — 9.4 percent of the population — have diabetes; 23.1 million of the nation’s seniors aged 65 and older are diabetic, and 84.1 million people aged 18 and older. A staggering one-third of the adult population is pre-diabetic. It’s a disruptive disease, and whatever you can do to make it easier for your clients is likely to endear you to them.

Those stats also make diabetes management a high priority for the Centers for Medicare and Medicaid Services (CMS). The sheer volume of patients makes diabetes a prime target for trying new models that may result in savings for CMS and better outcomes for patients.

The Diabetes Self-Management Training (DSMT) program includes instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin- dependent; and motivation for patients to use the skills for self-management.

“It’s all about integrating some of these normal models like pharmacies with primary care,” says Sandra Canally, RN, founder and CEO of The Compliance Team. “When we’re talking about diabetes, there is a lot of overlap between what the physician and the pharmacy does.”

DMEPOS suppliers can be reimbursed for giving this training if they are enrolled with the A/B MAC and meet the accreditation standards. DME and pharmacy providers must enroll as Medicare Part B providers to bill for the DSMT benefit, even if they are already enrolled as Medicare suppliers.

While reimbursement for DSMT has been available to DMEs for a while, in the past they’ve had to seek accreditation from CMS-approved national accrediting organizations such as the American Diabetes Association and American Association of Diabetes Educators (AADE) to get reimbursed. That meant that many DMEs weren’t exposed to the opportunity or didn’t pursue the separate accreditation it requires.

The Compliance Team, Inc., is getting ready to do DSMT accreditation. “We are the first provider-accreditor to be approved,” Canally says. “I look for revenue streams for both The Compliance Team and our customers. We already accredit pharmacies and DMEs. This is an add-on to what we already offer.”

Canally is expecting CMS to approve the company’s Medicare Diabetes Education Provider (MDEP) accreditation program early next year. That gives clients some time to set the stage before raising the curtain on your new act. It may be a major undertaking so Canally recommends getting your Rockettes in a row as soon as you can. “It typically would take that long to get…their policies in place and get patients enrolled in classes and so forth“ to be ready for accreditation.

WHAT DOES IT TAKE?

You should be ready to become the patient’s bridge between the care provider and real life. Busy care providers may explain the disease to the patient, tell them what they need to do, write a script and send them out the door. Imagine being that patient: you just found out you have a disease, the consequences of not changing your behavior are terrifying, and you have no idea who to ask for help.

“It can be very overwhelming. You’re pushed through a lot of appointments with your doctor and then you go home,” says Lisa Anderson, Education & Outreach coordinator at Universal Software Solutions, Inc. “Patients are looking for someone to tell them how to do it; things their doctors are not telling them.”

Being a diabetes hub will mean your business will have to develop a more intimate relationship with diabetes patients. It involves individual goal-setting, practical education, advising about diet and exercise, outreach, cheerleading and measuring progress. You’ll be helping patients with things like weight management and risk factors like obesity and smoking. In short, trying to replace unhealthy habits with healthy ones — and that’s in addition to providing products designed to address their needs.

The benefit lets you offer training and services up to 10 hours per patient in the first year, which translates to $350 to $450 per patient, Canally says. The training consists of one hour of one-on-one counseling with the patient, plus nine hours of training that will be offered in a group setting unless one of the following exceptions applies:

• No DSMT group class is available for two months or longer from the date on the referral.
• The referring provider indicates on the referral that the beneficiary has one or more barriers to group learning; such as reduced vision, hearing or cognition; a language barrier; or the patient is non-ambulatory.
• The referring provider indicates on the referral that the beneficiary needs additional insulin training.

Patients who complete the first 12-month period may qualify for up to two hours of follow-up training each calendar year after that. To qualify for reimbursement, the patients’ physicians must certify that they have diabetes (a pre-diabetes diagnosis is not eligible), write a prescription for the classes, and you have to be accredited as a DSMT provider. You will have to bring on a dietician, nutritionist or diabetes educator to do training; that can be a staff member or a contractor, as long as it meets the legal requirements and your patients’ needs. That trainer will need 15 hours of specialized continuing education.

You may want to enlarge your consultation space or add new features. Instead of a hard-edged cubicle, you may want a room with comfy chairs and soothing music. You may even want to carve out a dedicated space for classes, counseling and just to let patients decompress from the overload of managing a chronic condition — especially if they are newly diagnosed.

“Their business needs to feel like a medical community center, a space where they can take a newly diagnosed patient and explain to them how to test and how to do a shot,” Anderson says.

You may also need to do some community networking. While you probably won’t be providing exercise or cooking classes, you will be expected to point patients to resources that will. Those might include everything from Internal or external group meetings, locally or online; ongoing medication management; continuing education; physical activity programs; weight loss support; smoking cessation options; public facilities like swimming pools or Parcourse trails; diabetes magazines, websites or apps; and even grocery stores.

STICKING TO THE SCRIPT

You’ll have to develop a care plan for each patient, but it’s likely many will have common elements. Setting personal goals helps patients keep their eyes on the prize and stick to their plans. Instead of aiming for marks on meters and scales, help patients set goals such as, “‘I want to be healthy enough to play with my grandson,’ or ‘I want to not be winded or so overweight that I can’t go up a flight of stairs,’” Canally says. “In all of our programs, we set patient goals about what matters most to them.”

It may come as a surprise, but not everybody can cook. Your younger diabetes patients may have grown up eating fast food, microwaved pizza and swilling soda (see “What’s For Lunch?”on page Rx8) Bringing in a nutritionist to do a class on healthy food choices is an example of group training, while learning to cook healthy could be an individual goal.

In terms of merchandising, you can stock items that diabetes patients need — from sugar-free over-the-counter medications to insulin pumps to diabetic shoes — and make sure they are aggregated into one display to make it easy for patients to find what they need. “If Joe’s Pharmacy wants to be a diabetic hub for their diabetic patients, they need to have these products,” says Canally. Some items are eligible for reimbursement to accredited providers. “If they’re just doing strips and meters, they need to think seriously about adding diabetic shoes, the insulin pumps, the other DME items. Before they can bill for those items they need to be accredited for those as well.”

Once you have the elements in place, it’s time to play the overture and make sure providers know what you can provide. “One of the things that we emphasize in using these value-based care programs is to add these things and take it to the prescribers, so the prescribers know that your pharmacy is specializing in diabetes and all the things you offer,” Canally says. “Having Joe the pharmacist go to the physician and outline all of the things that the pharmacy is doing, then Dr. Smith knows, ‘I’m going to send my diabetes patients to Joe.”

Another selling point to physicians is that new rules will rate them based on outcomes. “The physicians and the plans both have what CMS refers to as star ratings,” Canally explains. “One of the things kicking in in 2020 is that the physicians will be scored according to how they perform with various measurements. A few of those measurements relate to diabetes. It’s another way the DME can go to the physician and say, ‘By better managing those patients with regard to medication therapy management, self-management training and the education component we offer, the products we have, it becomes a one-stop-shop for diabetes.’ If the Dr. Smith’s patients are managed and there’s good outcomes with those patients, Dr. Smith will get a good rating, which means that he gets more money.”

CMS also encourages DMEPs to do outreach in the community to make sure patients know where to find them.

If all this sounds daunting, the good news is that your accreditor, software vendor and distributor can help you manage different aspects of your hub (see “The Personal Touch” on page Rx 6).

CMS has resources to help DSMT providers market their services. The Diabetes Self-Management Education and Support Joint Position Statement User Guide can be used as the basis for presentations to physicians, community groups, educators and others. Educators can use the Joint Position Statement and algorithm to communicate with providers who refer as well as those who do not make referrals. The guide includes a sample provider letter, DMST business plan, and resources from the AADE, including a Tips for Reaching Providers sheet and PowerPoint presentation.

For more information about offering the DSMT benefit, visit the CDC website at www.cdc.gov.

This article originally appeared in the DME Pharmacy December 2019 issue of HME Business.