Quality Measurement and Improvement Under the New Medicare Prescription Drug Benefit

1
Quality Measurement and Improvement Under the New
Medicare Prescription Drug Benefit

• Data Integration
• (Information Integration)
• Improving Patient Care
• November 17, 2005
• Anita Franzione, DrPH, MPA
• Project Manager, Retiree Markets
• Aetna, Inc.

2
Aetna Prescription Drug Plans

• Two Plans
• Medicare Advantage with Prescription Drug
  (also know as MA-PD) Plan
• Prescription Drug Plan (also know as PDP)
• Both will have Medication Therapy Management
  Program (also know as MTMP) as part of the plan
• MTMP is KEY to making Medicare Part D successful
  and that success is based on INFORMATION

3
Aetna Medication Therapy Management Programs

• Components of MTMP Programs
• Formulating drug treatment plans
• Managing high cost specialty meds
• Evaluating and monitoring patient response to
  drug therapy and assisting with compliance
• Providing education and training
• Coordinating medication therapy with other care
  management services
• Health risk or status assessments (MA-PD plan
  only)
• Med Query for information (MA-PD plan only)

4
Criteria for MTMP Eligibility

• To be eligible for participation in an MTMP, all
  three criteria must be met.
• The beneficiary
• Must have multiple chronic diseases,
• Must be using multiple part D drugs, and
• Is likely to incur annual costs for covered Part
  D drugs that exceed 4,000.

5
Aetnas MTM ProgramCriterion 1

• Multiple Chronic Diseases
• Selection based on high cost, high morbidity,
  prevalent, and difficult to manage diseases
• Any two out of six chronic diseases
• Cardiovascular disease
• Asthma/chronic obstructive pulmonary disease
• Diabetes
• Chronic renal failure
• Cerebrovascular disease
• Rheumatoid arthritis
• Use drugs as proxy and medical claims data for
  disease identification

6
Aetnas MTM Program Criterion 2

• Multiple Covered Part D Drugs
• Six or more unique covered Part D drugs
• Expected outcomes
• Address polypharmacy and over-utilization
• Look for opportunities to decrease complicated
  drug regimens that may lead to non-compliance,
  drug misadventures, increased costs for the
  member

7
Aetnas MTM Program Criterion 3

• Total Incurred Cost for Covered Part D Drugs
• Beneficiary is likely to incur annual costs of at
  least 4,000 for all covered Part D drugs
• Three analytical models developed by Aetna to
  predict future drug costs
• Other modeling tools to be incorporated such as
  those based on PRGs

8
Stages of Aetnas MTM Program

• Identification of members through informatics
  programming
• Information packet with relevant demographic,
  pharmacy, medical, and lab data is compiled
• Information packet feeds into the electronic
  documentation system
• Pharmacotherapy specialist (PTS) evaluates data
  for risk-stratification and prioritization
• PTS performs outreach, documentation, follow-up,
  referral

9
MTM Workflow to identify members with an
indication of opportunity for improvement in the
use of medication polypharmacy, drug
interaction, and drug compliance
Database Demographic, Pharmacy, Medical, Lab
data
Member Identification and Information Packet
Criteria algorithms
Previously IDd members excluded
Risk Stratification and Outreach by PTS
Electronic Documentation Management System
Case management referral
For MA-PD only For PDP, special cases
10
Aetnas MTM Program Information Packet

• The information packet contains 51 items of
  information to be used for medication management.
• The information packet will use all available RX
  claims data (and medical and lab data for MA-PD
  only).
• The information packet will automatically
  populate the necessary fields in the electronic
  documentation management system.
• Hard copies of the information packet will be
  used by PTS to assist with outreach.
• All MTM records will be maintained for a period
  of no less than ten years.

11
Aetnas MTM Program Information Packet

• The fields in the information packet will contain
  data such as
• Lipid lab values, compliance indicators,
  drug-drug drug-age interactions, disease
  indicators
• Predictive modeling pharmacy risk group (PRG)
  scores from the risk stratification algorithms
• Risk designation values for further
  stratification. The various data indicators are
  assigned specific values based on severity level
  and importance. The sum of these values produces
  the aggregated risk designation value.
• Disease management and case management activity
  information (for MA-PD limited ability for PDP)
• The number of maintenance acute drugs,
  estimated annual RX costs, past year RX costs,
  YTD RX costs

12
Aetnas MTM Program Outreach

• The pharmacotherapy specialist (PTS) will assess
  the beneficiarys drug history, medical, and lab
  data and determine the action and outreach to be
  taken.
• The program is a collaborative effort between the
  beneficiary, PTS, RX case manager, physician,
  dispensing pharmacist, other health care
  providers, and care giver.
• Opt-out program beneficiaries are automatically
  enrolled unless disenrollment is requested.
• MTM program content is reviewed by pharmacy
  therapeutics, quality management, and Medicare
  committees. Updates provided to these bodies.
  Insight and input of committees is requested.

13
MTM Outreach Activities

• Member education
• Compliance
• Use of generics
• Understanding the need for drug therapy
• Drug information
• Social services
• Available community resources
• Assistance from local programs
• Appointments with physicians
• Transportation needs

14
MTM Outreach Activities

• Physician consultation
• Drug-drug, drug-age, drug-disease interactions
• Changes in therapy (strength, dosing schedule,
  drug)
• New information about drugs or patients drug
  history
• Coordination of medication management with
  physicians
• Special considerations of the patient requiring
  review of current medications
• Education to the physician

15
MTM Outreach Activities

• Discussion with pharmacists
• Dispensing pharmacists (retail, mail order,
  specialty drug)
• Long-term care pharmacists
• Consultant pharmacist for LTC facility
• Drug information and poison control pharmacists
• Academic pharmacists
• Professional organizations

16
MTM Outreach Activities

• Referral to and consultation with case
  management, disease management, and medical
  directors
• Beneficiary has special needs, especially social
  needs (MA-PD and limited PDP)
• Beneficiary has complicated drug regimen and
  multiple diseases (Both)
• Beneficiary needs coordination of care from case
  or disease management (MA-PD only)
• Beneficiary requests specific information (past
  medical history MA-PD only and Rx claims)

17
CMS Reporting of MTM

• The number of beneficiaries who met the criteria
  for the MTMP in the specified time period
• The number of beneficiaries who participated in
  the MTMP at any point during the time period
  specified
• The number of beneficiaries who disenrolled from
  the MTMP at any time during the specified time
  period
• The number of beneficiaries who declined the
  offer to participate in the MTMP during the
  specified time period
• For each beneficiary participating in the MTMP as
  of the last day of the reporting period
  specified, the total prescription cost of all
  medications on a per MTMP beneficiary per month
  basis
• Reporting periods are Jan-June and Jan-Dec due on
  December 31 and February 28

18
Example of MTM for a Patient with

• Major Dx
• Cardiovascular (CAD, HF) diabetes, depression
• Drug Therapy
• Mobic (rheumatologist)
• Ibuprofen, Prozac, propoxypheneAPAP (internist)
• Ultracet (pain specialist)
• Prevacid (gastroenterologist)
• Marplan (psychiatrist)
• Digoxin, lisinopril, metoprolol, furosemide
  (cardiologist)
• Metformin (endocrinologist)
• Compliance issues identified with lisinopril,
  metoprolol, metformin

19
Assessment of Problem

• Therapeutic duplication with Mobic and ibuprofen
• Acetaminophen toxicity potential
• GI problems from Mobic, ibuprofen, and Ultram
  requiring Prevacid
• Drug interaction with Prozac and Marplan
• Propoxyphene not appropriate in the elderly
• Metformin contraindicated in HF

20
MTMP Components for PDP

• Medication history assessment by PTS
• Coordination of medication management
• Education (compliance, generic drugs,
  diseases/conditions, alternative therapies,
  polypharmacy issues, interactions and drug safety
• Referral to cm for socio-economic needs
  (financial assistance, transportation,
  Medicaid/SSI, caregiver issues.

21
Additional MTM Activities for MA-PD

• All PDP activities listed previously
• Lab and Medical claims data available for
• Disease identification/confirmation
• Predictive modeling
• Referral from PTS to case manament for all the
  case management programs available thru Aetna
• Disease management

22
Aetna MA-PD

• Currently offer MA plan in 5 states
• 2006 MA and MA-PD will be in 13 states
• Members with both a Medicare Advantage Plans and
  a Prescription Drug Plan
• Information from all claims and possible case
  management and disease management on the member
  is all in one area
• This information is then feed into Aetnas
  systems to develop cases on these members

23
MA-PD MTMP Workflow Referral Process
Referral Source Informatics Identification
via
24
MA-PD MTMP Workflow Referral Process
Referral SourcePharmacotherapy Specialist (PTS)
via
25
Aetna PDP

• Aetna offers a PDP plan in all 50 states
• a national program to provide coverage in
  multiple areas or out of area pharmacies in the
  members network
• Information from pharmacy claims only are fed
  into Aetnas systems to develop a case on these
  members

26
PDP MTMP Workflow Referral Process
Referral Source Informatics Identification
via
27
The Future of MTM at Aetna

• Use of external MTM programs and providers
  (retail pharmacists for direct contact and
  outreach)
• Outcome studies in collaboration with CMS and
  other institutions
• E-prescribing and electronic records initiatives
• Personal Health Records via web-based access
• Best practices implementation

28
HoweverIt will not work without INFORMATION!

• Face Obstacles on obtaining member information
  for both plans
• For PDP, only pharmacy claims and only current
  claims, no past history claims
• For MA-PD, only claims information, no true
  medical information. Currently within our
  Medicare Population, approximately 15 of our
  members are in case management a strong, robust
  program and with PD made even stronger but still
  not a true whole member picture.

29
First Medicare Payment