The Value of Medication Therapy Management Services

1
The Value of Medication Therapy Management
Services
2
ORIGINS AND DEVELOPMENT OF MTMS
3
Milestones in the Evolution of the Pharmacist as
a Clinician
1949 The Elliott Commission recommends that
pharmaceutical education move toward a doctor of
pharmacy degree. 1973 APhA endorses the concept
of clinical pharmacy in practice. 1975 The
Millis Commission recommends more clinical
education and courses in social and behavioral
sciences to recognize pharmacists growing
patient care roles.
4
Milestones in the Evolution of the Pharmacist as
a Clinician
1990 Hepler and Strand propose the concept of
Pharmaceutical Care Pharmaceutical care is the
responsible provision of drug therapy for the
purpose of achieving definite outcomes that
improve a patients quality of life 1990 OBRA
90 requires pharmacists to perform DUR and to
offer to counsel Medicaid patients most states
eventually extend these requirements to all
patients.
5
Milestones in the Evolution of the Pharmacist as
a Clinician
1991 APhA proposes Pharmacys mission The
mission of Pharmacy is to serve society as the
profession responsible for the appropriate use of
medications, devices and services to achieve
optimal therapeutic outcomes
6
Milestones in the Evolution of the Pharmacist as
a Clinician
1993 NCPA proposes the concept of Pharmacist
Care Pharmacist Care is a comprehensive
approach to pharmacist-directed patient care
management through which pharmacists provide an
expanded level of patient care that focuses on
disease prevention and wellness programs and
includes monitoring, evaluating, counseling,
intervening and directing medication-related
therapies to enhance patient care and improve
health outcomes
7
Milestones in the Evolution of the Pharmacist as
a Clinician
2003 Medicare Modernization Act (MMA) is
passed creates an outpatient prescription drug
benefit for Medicare recipients. The MMA
recognizes patients need for medication therapy
management services (MTMS) and the role of
pharmacists as providers of MTMS.
8
To Medication Therapy Management Services

• The term MTMS became widely accepted after it was
  included in the Medicare Modernization Act in
  2003
• The foundation of MTMS was built through the
  development of pharmaceutical care
• MTMS is not limited to any specific population or
  payer group

9
Purpose of Medication Therapy Management Services
(MTMS)

• To optimize therapeutic outcomes
• To decrease the likelihood of adverse events
• To enhance patient understanding and adherence
• To reduce overall healthcare spending

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
10
Pharmacists Evolving Role
From Dispensing Services
to a clinical service provider
11
Pharmacys Definition of MTMS

• Services provided by a pharmacist that improve
  treatment outcomes for individual patients
• A professional service to promote the safe and
  effective use of medications
• A way to provide better care for patients
• Promotes collaboration among the patient, the
  pharmacist, and the patients other health care
  providers
• .

Bluml BM. Definition of medication therapy
management development of professionwide
consensus. J Am Pharm Assoc. 20054556672
12
CMS MTMS Requirements

• The CMS MTMS Requirements only apply to the
  Medicare population
• CMS is regularly evaluating this service, and the
  program definitions will likey evolve over time.
• Currently, CMS requires that all Medicare Part D
  Plans have an MTMS program which
• Ensures optimum therapeutic outcomes for targeted
  beneficiaries through improved medication use
• Reduces the risk of adverse events
• Is developed in cooperation with licensed and
  practicing pharmacists and physicians

www.cms.hhs.gov
13
CMS MTMS Requirements

• Currently, CMS requires that all Medicare Part D
  Plans have an MTMS program which
• May be furnished by pharmacists or other
  qualified providers
• May distinguish between services in ambulatory
  and institutional settings
• Is coordinated with any care management plan
  established for a targeted individual under a
  chronic care improvement program (CCIP)
• Describes the resources and time required to
  implement the program if using outside personnel
  and establishes the fees for pharmacists or
  others

www.cms.hhs.gov
14
Establishment of Billing Codes

• Three pharmacist only CPT professional service
  codes to bill third-party payers for MTM Services
  delivered face-to-face between a pharmacist and a
  patient
• 99605 is to be used for a first-encounter
  service (up to
• 15 minutes)
• 99606 is to be used for a follow-up encounter
  with an established patient (up to 15 minutes)
• 99607 may be used with either 99605 or 99606 to
  bill additional 15-minute increments.
• Classified as Category 1 and became eligible for
  use January 1, 2008.

Beebe M, Dalton JA, Espronceda M, et. al.
Current Procedural Terminology 2009. American
Medical Association Chicago, IL.
15
CPT Code Definition of MTMS

• Medication Therapy Management services (MTMS)
  describe face-to-face patient assessment and
  intervention as appropriate, by a pharmacist 
• MTMS includes the following documented elements 
  
• review of the pertinent patient history
• medication profile (prescription and
  non-prescription)
• recommendations for improving health outcomes and
  treatment compliance. 

Beebe M, Dalton JA, Espronceda M, et. al.
Current Procedural Terminology 2009. American
Medical Association Chicago, IL.
16
ACTIVITIES INCLUDED IN MTMS
17
MTMS Activities

• Assess patients health status
• Devise medication treatment plan
• Select, modify and administer medications
• Review current medications and identify
  drug-related problems
• Communicate care to other providers
• Provide patient education
• Refer patients for broader disease management
  services

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
18
The Spectrum of Pharmacist-Provided MTMS

• Comprehensive or Targeted Medication Therapy
  Reviews
• Adherence Services
• Based on the number and/or type of medications
• Targeted Medication Intervention Programs
• High-alert and/or high-cost medications
• Targeted patient population (i.e. geriatrics,
  pediatrics)
• Disease State Management
• Interdisciplinary approach to achieve therapeutic
  goals
• Example disease states Diabetes, Cholesterol,
  Asthma
• Health and Wellness Services
• Immunizations
• Wellness screenings
• Smoking cessation
• Weight management

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
19
Components of the MTMS Core Elements Service
Model

• Medication Therapy Review (MTR)
• a review of all medications including
  prescription, nonprescription, herbal products,
  and other dietary supplements
• Personal Medication Record (PMR)
• Medication-Related Action Plan (MAP) for the
  patient
• Intervention and/or Referral
• Documentation and Follow-Up

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
20
Medication Therapy Reviews

• A Medication Therapy Review
• (MTR) is provided at routine
• intervals by a pharmacist
• Annual comprehensive MTR
• Additional comprehensive MTRs
• as needed
• Targeted MTR at any time to address new or
  ongoing medication-related problems

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
21
What Do Patients Get From Care Aligned With the
MTMS Core Elements Model?

• A complete list of all
• of their medications
• Personal Medication Record
• (PMR)
• A guide for managing their
• medications and related
• conditions
• Medication-Related Action Plan
• (MAP)

APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
22
Value of a Personal Medication Record

• The medication record helps give the doctors a
  better picture of whats going on with me.

23
Value of MTMS
Having the help of a person who specializes in
medications, which impacts me on a daily
basisputting drugs in my body.
24
PHARMACISTS ROLE IN THE HEALTH CARE TEAM
25
they are integral members of the health care team!
Pharmacists do not work in silos.
26
Physicians Value Pharmacists

• Working with the pharmacist has helped me to
  focus on the things that only I can do as a
  physician.

27
Medication Therapy Management Process
ASSESSMENT
? Evaluate appropriateness, effectiveness,
safety, and compliance with medications ?
Identify drug therapy problems

Practitioner
Patient

CARE PLAN
Experienced Decision Making
Medication Experience
? Resolve drug therapy problems ? Establish goals
of therapy ? Interventions
? Philosophy of Practice ? Social Obligation ?
Responsibility to identify, resolve, and
prevent drug therapy problems ?
Patient-centered approach ? Caring
? Todays wants and needs ? Responsibility to
participate in information sharing and
decision making
FOLLOW-UP
? Evaluate progress in meeting goals of therapy ?
Record actual patient outcomes ? Reassess new
problems
Therapeutic Relationship
28
Pharmacist/Prescriber Relationship
29
Pharmacists Communication with other Health
Providers

• Pharmacists will communicate regularly with
  patients primary care provider, and other health
  care team members as appropriate
• Describe assessment
• Describe and rationalize recommendations for
  medication changes
• Recommendations for follow-up

30
Medication Recommendations

• Pharmacists may make recommendations in several
  ways
• Directly to the patient
• Over-the-counter changes, general adherence tips,
  managing side effects
• Through the prescriber
• Changes in prescription medications
• Directly to the patient under a collaborative
  practice agreements
• Allows pharmacists to make adjustments to
  prescription medications via protocol

31
VALUE OF MTMS
32
APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
33
How do we define value?

• Value on investment
• Economic
• Overall cost savings or cost
• Clinical
• Improvements in health outcomes
• Humanistic
• Patient satisfaction, improved quality of life,
  worker productivity
•  

34
EVIDENCE OF THE VALUE OF MTMS
35
Studies Illustrating Value of MTMS

• Asheville Project Diabetes
• Asheville Project Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project

36
Asheville Project Diabetes

• Evaluation of outcomes following community based
  provision of MTMS to patients with diabetes
  covered by a self-insured employer group
• Longitudinal study with pre- and post- data
• Participants were provided incentives including
  waiver of all copays for diabetes medications and
  supplies
• 5 years of follow-up data
• 187 participants entered the program, with 26
  continuing at 5 years

Cranor CW, Bunting BA, Christensen DB. J Am Pharm
Assoc. 20034317384.
37
Asheville Project Diabetes

• Pharmacists performed the following as part of
  this study
• Set and monitored treatment goals
• Glucometer training
• Adherence monitoring
• Basic physical assessment, including foot exam,
• blood pressure and weight
• Diabetes education
• Referral to other providers as needed

Cranor CW, Bunting BA, Christensen DB. J Am Pharm
Assoc. 20034317384.
38
Clinical Outcomes of MTMSThe Asheville Project -
Diabetes
Cranor CW, Bunting BA, Christensen DB. J Am
Pharm Assoc. 20034317384.
APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
39
Asheville Total Health Care Costs1
Cranor CW, Bunting BA, Christensen DB. J Am
Pharm Assoc. 200343173-84.
APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
40
Average Annual Diabetic Sick-Leave Usage (City of
Asheville)
APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
41
Key Findings Asheville Diabetes

• Economic benefit
• Total health care costs for patients decreased
• Prescription costs increased, but medical costs
  decreased
• Clinical benefit
• Significant improvement seen in A1C and LDL
• Humanistic benefit
• Decreased sick leave increased worker
  productivity

Cranor CW, Bunting BA, Christensen DB. J Am
Pharm Assoc. 200343173-84.
42
Asheville Project Asthma

• Evaluation of outcomes following community based
  provision of MTMS to patients with asthma covered
  by a self-insured employer group
• Longitudinal study with pre- and post- data
• Participants were provided incentives including
  waiver of all copays for asthma medications and
  supplies
• 5 years of follow-up data
• 207 participants entered the program

Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
43
Asheville Project Asthma

• Pharmacists served as care managers and met with
  subjects an average of every 3 months
• Reviewed asthma action plans
• Medication assessments of inhaler use
• Assessment of inhaler technique
• Review of symptoms and peak flow meter readings
• Recommendations for treatment changes were sent
  to physician

Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
44
Economic Outcomes of MTMSThe Asheville Project -
Asthma
Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
45
Clinical Outcomes of MTMSThe Asheville Project -
Asthma
Improved Asthma control sustained over 5 years
Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
APhA. Pharmacists Improving Care and Reducing
Costs for Your Plan Participants. Available at
www.pharmacist.com
46
Key Findings Asheville Asthma

• Economic benefit
• Decreased percentage of asthma patients requiring
  emergency and hospital care
• Clinical benefit
• Improved asthma control sustained over 5 years
• (as evidenced by FEV1 measurements)

Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
47
Diabetes Ten City Challenge

• Employer-funded, collaborative health management
  program for diabetes using community-based
  pharmacists in 10 cities across the USA
• Pharmacists were located in
• Independent pharmacies
• Chain pharmacies
• Ambulatory care clinics
• On-site workplace locations
• Participants received waived co-pays for
  medications.
• 573 patients participated

Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391.
48
Diabetes Ten City Challenge

• Pharmacists performed the following as part of
  this study
• Applied a prescribed process of care based on
  clinical assessments and progress to goals
• Worked with patients to set individualized
  self-management goals
• Recommended changes in therapy when appropriate

Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391.
49
10 City Challenge Economic Outcomes after Year 1
Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391.
50
10 City Challenge Clinical Outcomes after Year 1
HEDIS process measures for patients with diabetes
Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391.
51
Key Findings 10 City Challenge

• Economic benefit
• Total health care costs were less than predicted
• Prescription costs increased, but overall health
  care
• costs decreased
• Clinical benefit
• Increased percentage of patients meeting HEDIS
  process measurement goals for patients with
  diabetes

Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391.
52
Minnesota Experience Project

• Evaluation of MTMS provided at 6 ambulatory care
  clinics over 1 year
• 285 patients received MTMS
• HEDIS goals for hypertension and dyslipidemia
  were evaluated
• Study patients were required to have 1 of 12
  study conditions
• Return on investment was calculated at 121

Isetts, et al., J Am Pharm Assoc.
200848(2)203-211
53
Minnesota Experience Project

• Pharmacists in this study
• Used a consistent and systematic patient care
  process
• Established goals of therapy in collaboration
  with patients and primary care providers
• Made recommendations for changes in therapy as
  appropriate

Isetts, et al., J Am Pharm Assoc.
200848(2)203-211
54
Economic Outcomes from the Minnesota Experience
Project
55
Clinical Outcomes from the Minnesota Experience
Project
HTN n 254 p0.03
Dyslipidemia n 254 P0.001
Isetts, et al., J Am Pharm Assoc.
200848(2)203-211
56
Key Findings Minnesota Experience Project

• Economic benefit
• A 121 return on investment was seen
• Savings was seen in facilities costs
• Per person per year costs decreased from 11,965
  to 8,197
• Clinical benefit
• The MTM intervention group had a higher
  percentage of patients meeting HEDIS goals for
  hypertension and dyslipidemia

57
Limitations of Current Evidence

• Most of the data comes from self-insured employer
  groups
• Individual studies are small
• Ten City Challenge was the largest with 573
  participants
• Much of the evidence is focused on specific
  disease states

58
Summary of evidence of Value of MTMS

• Economic
• Multiple studies have shown positive results on
  total health care costs, creating a positive
  return on investment
• Clinical
• Multiple studies have indicated improved in
  clinical outcomes, specifically in diabetes,
  asthma, hypertension and dyslipidemia
• Humanistic
• The Asheville project has demonstrated reduced
  employee sick days and increased productivity.

Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49(3) 383-391. Isetts, et al., J Am Pharm
Assoc. 200848(2)203-211 Bunting BA, Cranor CW.
JAPhA. 2006 46133-147. Cranor CW, Bunting BA,
Christensen DB. J Am Pharm Assoc. 200343173-84.
59
ELEMENTS OF MTMS BENEFIT DESIGN
60
Elements of MTMS Plan Design

• Eligibility
• Reimbursement structure
• Member engagement strategy
• Incentives

61
Eligibility

• Eligibility for a MTMS benefit can be based on
• Number of medications
• Specific chronic conditions
• Total amount of prescription expenditures

62
Reimbursement Structure

• Recommend utilizing the MTMS CPT billing codes
• May use them as defined as time-based codes, or
  use a cross-walk relative value scale

63
Example Minnesota Medicaid

• MHCP will reimburse only for face-to-face
  encounters and based on the lowest of five
  patient need levels, according to the following
  qualifying criteria
• The number of medications the patient is
  currently taking
• The number of drug therapy problems the patient
  has at present and
• The number of medical conditions for which the
  patient is currently being treated.
• CPT Codes (Time Based Codes)
• Based on adopted Minnesota Medicaid law
• 99605
• 99606
• 99607

64
Example MN Medicaid Payment Structure
65
Example Outcomes Pharmaceutical Health Care
66
Member Engagement Strategy

• May offer copay reductions or waivers
• For all medications
• For medication associated with a targeted medical
  condition (i.e., diabetes)
• Offer reduced copay (or none) for MTMS

67
Whats In It For the Payer?

• MTMS results in decreased overall healthcare
  costs
• Prescription costs will likely increase, but this
  is compensated by an overall decrease in costs
• Pharmacists can provide MTMS as a member of the
  health care team and medical home model
• Increased member satisfaction
• Mechanisms for MTMS claims processing are well
  established through CPT codes

68
Whats In It For the Patient?

• MTMS provides patients with improved health
  outcomes from optimizing medication use
• This includes decrease emergency department
  visits and hospitalizations
• Increased understanding of medications and
  disease management
• Improved quality of life

69
Summary

• Medications are a standard in the care of chronic
  diseases
• Pharmacist delivered Medication Therapy
  Management Services are well documented to
  decrease health care costs while increasing the
  quality of health care