Insurance refuses to pay for new services

Ron DeVizia is finding that it's easier to get paid for filling prescriptions than for dispensing advice.

DeVizia, Kerr Drug's manager of diabetes services, has designed an education program to teach diabetic patients how to manage their disease. But while Medicare will pay the $299 tuition, private insurers and Medicaid refuse.

The problem is that insurers pay pharmacists only to provide drugs, not health care services, DeVizia said. So far, his efforts to change the classification for his staff of 15 clinical pharmacists have been unsuccessful.

"My goal is that anyone who wants diabetes education in the community should have that opportunity," he said. "It's frustrating."

The problem also affects Kerr Drug on a competitive level.

Pharmacies have seen their profits on drug sales decline after private insurers took over Medicare's prescription drug program this year, and the pharmacies are trying to figure out other ways to make money. A key part of Kerr Drug's new strategy is to provide health care services along with medicines.

"I'm trying to offer this as a service to make our pharmacy chain unique, and that's a struggle," DeVizia said.

His pharmacy in Zebulon has trained about 300 patients since the program began in June 2005. Kerr Drug also offers its diabetes education program in Benson, Chapel Hill, Fuquay-Varina and Raleigh locations.

All but one of the program's pharmacists have completed, or are currently completing, a one-year community practice residency that focuses on patient care, clinical management and disease management. That's on top of their doctoral degrees in pharmacy.

Kerr Drug's diabetes education program consists of three small-group classes focusing on diabetes complications and care standards, healthful eating and exercise, managing stress and changing behavior.

Participants also receive two one-on-one sessions. In the first, they talk with pharmacists about their medications, monitoring their blood sugar and caring for their feet, which is important for diabetics. In the second, they meet with a dietitian to learn about counting carbohydrates and a proper diet.

The pharmacy offered the seven-hour program for free until December, when accreditation by the American Diabetes Association gave it the ability to bill Medicare. But once Medicare started paying for the classes and one-on-one meetings, Kerr Drug also had to start charging other patients, DeVizia said. The government insurance program won't pay for services that some people receive for free.

Since then, DeVizia's claims have been rejected by every private health plan he has tried, he said, and he's having trouble getting insurers' attention about making changes.

Blue Cross and Blue Shield of North Carolina, the state's largest health insurer, places primary importance on diabetes care and management by doctors, said spokesman Mark Stinneford. What's more, the company already has its own diabetes management program that provides free equipment, books, online resources and phone-based support from nurses, he said.

Still, health care professionals have indicated interest in the program, DeVizia said. Nearly 70 percent of doctors, nurse practitioners and physician assistants who responded to a survey said they would be likely or very likely to refer patients to Kerr Drug.

With lower reimbursements driving doctors to squeeze seeing more patients into each day, some need to turn to other health care providers for diabetes education, he said. Kerr Drug responds by supplying the doctors with reports on how well their patients are managing their disease.