Diabetes Chronic Condition Management and Medical Billing: A Collaboration Between a Health Plan and Community Pharmacies

Session Description: Managing uncontrolled diabetes is a daily and complex journey for many individuals. Involving the right partners is necessary to improve health outcomes for diabetes patients. Our organization needed a path to leverage the expertise, reach, and convenience of community pharmacists. We partnered with another company to develop an innovative pilot program to improve or achieve goal hemoglobin A1c values for Medicaid and Medicare patients with diabetes through pharmacist-driven engagement. Our organization paid pharmacists per intervention recommended and pharmacists that improved diabetes control with an improved hemoglobin A1c test result also received a value-based payment. After the pilot, we saw positive results with improvement in medication adherence and decrease in total cost of care. In 2024, our organization redesigned the program to better align with quality measures, expand the program, and to better engage with pharmacies by implementing medical billing of diabetes hemoglobin A1c tests. Materials and presentations were created to market the program at the State Pharmacist Association regional meetings. For the improved diabetes management pharmacy collaboration , we created revenue streams for pharmacies to help improve diabetes and conducted trainings to increase awareness. We measured the improvement of this new program with data related to diabetes adherence, diabetes A1c control, diabetes A1c improvement, and cost savings.