Obesity care: Pharmacists ready and qualified

Provider status could jumpstart moving patients to better health

"Glen" weighs about 320 pounds. The multiple medications he takes for a host of conditions including type 1 diabetes can also cause him to retain water and add several dozen extra pounds from time to time. These weight fluctuations, in addition to his already being obese, make his diabetes especially difficult to control. Visits with his endocrinologist every other month simply aren’t enough, and without a car, Glen struggles to get to appointments anyway.

But between physician visits, Glen’s pharmacist, Andrew Bzowyckyj, PharmD, manages Glen’s diabetes—on a weekly basis when needed. And Glen doesn’t even have to go in for a visit.

“He uploads his insulin pump data to a computer, and I download all of his readings here in the clinic—his glucose values, his carbs, what he says he’s eating. We walk through the chart together over the phone,” said Bzowyckyj, who manages complex patients at an endocrinology clinic affiliated with the University of Missouri–Kansas City School of Pharmacy.

Nearly 10% of the U.S. population has diabetes. More than a quarter of Americans older than 65 years lives with the condition. In 2007, diabetes caused or contributed to more than 200,000 deaths and cost the U.S. economy $174 billion. By last year that cost had risen to an annual $245 billion.

Like Glen, almost 20% of people with diabetes have blood sugar levels considered “out of control.” Diabetes disproportionately affects people like Glen—poor people, people on Medicaid, people without transportation to their physician’s office. 

As the changing health care landscape is pushing health care facilities to lower costs and improve performance, many facilities are engaging pharmacists to help patients control their diabetes. Indeed, some studies show pharmacists are the health care providers best suited for this job, according to a 2007 study in the Annals of Pharmacotherapy. However, reimbursement barriers in most states prevent more pharmacists from stepping into this role.

Bzowyckyj can care for Glen and about five or six other patients like him each day because he is a clinical assistant professor at the University of Missouri–Kansas City. The university pays Bzowyckyj’s salary, and in exchange Bzowyckyj teaches student pharmacists who rotate in his clinic to learn how to do what he does. That way Bzowyckyj can see patients with diabetes every 2 to 3 weeks between their physician visits every 6–8 weeks.

“I’m making sure that they get their medicine, that they pick it up, that they can afford it, and that they know how to use it, and that it is working well.” Bzowyckyj also adjusts dosages within his scope of practice, makes recommendations for changes in medication regimen, and educates patients on meal planning, exercise, and other facets of living with diabetes. Without the university’s stake in his work, however, there wouldn’t be a simple way for the pharmacist to get paid.

Unlike almost any other health professional, pharmacists cannot bill Medicare, Medicaid, or most commercial insurance because they lack “provider status,” a qualification that CMS gives to health care providers that allows them to bill independently for services.

Though the endocrinology clinic where Bzowyckyj practices and bills insurance every time patients see a provider, payers reimburse for physician visits, but not for visits with a pharmacist.

“I’m trying to grow this program, but unfortunately I’m limited in capacity because there is not a lot of incentive,” Bzowyckyj said. “We’ve been able to launch a lot of pharmacist-led inpatient programs here at this hospital based on cost savings, but that has been a much more difficult sell on the outpatient side, mainly because of the lack of ‘hard dollars.’”

If Bzowyckyj’s services brought revenue to the university and health system, he believes they would invest in expanding those services. Likewise, if pharmacists around the country could bill for the health benefits they are capable of bringing to patients with diabetes, they would eagerly step into this role.

Some estimates suggest that as many as one in three American adults will have diabetes by 2050. Better control of the condition stands to bring immense savings to the U.S. health system and the economy at large. The government, including CMS and the military, bears 62% of the annual multibillion-dollar cost of diabetes. Yet CMS doesn’t deem pharmacists eligible to bill for managing patients with the costly disease.

“If a primary care physician is following someone every 2 to 3 weeks, that’s great, but you can rarely see your own family physician that often,” Bzowyckyj says. “You need to see somebody else in the meantime to fill that gap.”

Pharmacists, Bzowyckyj says, are qualified and ready.

“Pharmacists bring a unique skill set to other practitioners on the team. We don’t replace anybody, but we augment extremely well.”