The Value of Medication Therapy Management Services

1
The Value of Medication Therapy Management
Services
2
Purpose of MTMS

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

American Pharmacists Association
3
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
4
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

American Pharmacists Association
5
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

American Pharmacists Association
6
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

American Pharmacists Association
7
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
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MTM Pharmacist/Prescriber Relationship
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Pharmacists Communication with other Health
Providers

• MTM 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

10
Medications Recommendations

• MTM 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

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American Pharmacists Association
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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
•  

13
Studies Illustrating Value of MTMS

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

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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.
15
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.
16
Clinical Outcomes of MTMSThe Asheville Project -
Diabetes
Cranor CW, Bunting BA, Christensen DB. The
Asheville Project long-term clinical and
economic outcomes of a community pharmacy
diabetes care program. J Am Pharm Assoc.
20034317384.
American Pharmacists Association
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Asheville Total Health Care Costs1
1Cranor CW, Bunting BA, Christensen DB. The
Asheville Project Long-term clinical and
economic outcomes of a community pharmacy
diabetes care program. J Am Pharm Assoc.
200343173-84.
American Pharmacists Association
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Average Annual Diabetic Sick-Leave Usage (City of
Asheville)
American Pharmacists Association
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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

20
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.
21
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.
22
Economic Outcomes of MTMSThe Asheville Project -
Asthma
Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
23
Clinical Outcomes of MTMSThe Asheville Project -
Asthma
Improved Asthma control sustained over 5 years
Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
American Pharmacists Association
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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)

25
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
49e52-e60.
26
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
49e52-e60.
27
10 City Challenge Economic Outcomes after Year 1
Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49e52-e60.
28
10 City Challenge Clinical Outcomes after Year 1
HEDIS process measures for patients with diabetes
Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49e52-e60.
29
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 HEDIC
• process measurement goals for patients with
  diabetes

30
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
31
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
32
Economic Outcomes from the Minnesota Experience
Project
33
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
34
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 8197
• Clinical benefit
• The MTM intervention group had a higher
  percentage of patients meeting HEDIS goals for
  hypertension and dyslipidemia

35
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

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Summary of evidence of Value of MTMS

• Economical
• 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.

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Elements of MTMS Plan Design

• Eligibility
• Reimbursement structure
• Member engagement strategy
• Incentives

38
Reimbursement Structure

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

39
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

40
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

41
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
• High satisfaction rates among participants