The Opportunity for Comprehensive Medication Management

1
The Opportunity for Comprehensive Medication
Management
Presenter Name
2
Agenda

• The Need for Medication Management Services
• The PCMH Team as a Solution
• The Steps of Comprehensive Medication Management
• Impact of the Service
• Payment Approaches
• Case Studies

3
The Facts

• 75 of all healthcare costs are related to
  chronic disease
• After lifestyle interventions, medications are
  the primary weapons used in modern medicine to
  prevent disease and effectively control chronic
  disease
• Proper use of medications can lead to improved
  health, enhanced quality of life, and increased
  productivity when directly linked to clinical
  outcome goals.

So Why A Quality Gap?
4
The Facts

• Four out of Five patients leave with at least
  one prescription1
• One-third of all American adults take 5 or more
  medications
• Medicare beneficiaries with multiple illnesses
• See an average of 13 different physicians
• Have 50 different prescriptions filled each year
• Account for 76 of all hospital admissions
• Account for 88 of all prescriptions filled
• Account for 72 of physician visits
• Are 100 times more likely to have a preventable
  hospitalization than someone without a chronic
  condition2

1 The chain pharmacy industry profile. National
Association of Chain Drug Stores. 2001 2
Testimony of Gerard F. Anderson, Ph.D., Johns
Hopkins Bloomberg School of Public Health, Health
Policy and Management, before the Senate Special
Committee on Aging, 2 The Future of Medicare
Recognizing the Need for Chronic Care
Coordination, Serial No. 110-7, pp. 19-20 (May 9,
2007)
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HealthCare Landscape

• But what happens to those prescriptions?

Non-Compliant Behaviors
The Hidden Epidemic Finding a Cure for Unfilled
Prescriptions and Missed Doses. December, 2003.
The Boston Consulting Group and Harris
Interactive. Available at http//www.bcg.com/publ
ications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf.
Accessed August 16, 2004.
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Why Didnt They Take Their Medication?

• 24 forgetfulness
• 20 undesirable or debilitating side effects
• 17 medication was too costly
• 14 decided they didn't need the drug
• 10 difficulties in getting the prescription
  filled

The Hidden Epidemic Finding a Cure for Unfilled
Prescriptions and Missed Doses, December, 2003.
The Boston Consulting Group and Harris
Interactive. Available at http//www.bcg.com/publ
ications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf.
Accessed August 16, 2004.
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The PCMH Team Closes The Quality Gap

• Appropriate medications need to be recommended
  and prescribed,
• Patients need to thoroughly understand, have
  access to, and engage with their medications
• The most effective treatments (with continual
  evaluation modification) can produce optimal
  clinical and quality outcomes.

8
Why Is Medication Management Neededin the PCMH?

• Comprehensive medication management has been
  shown to facilitate the efficiency and
  effectiveness of the PCMH team in improving
  patient clinical outcomes, reducing morbidity and
  mortality, while lowering total healthcare
  costs.
• Medication Management is even more essential when
  multiple providers/prescribers are involved with
  complex patients

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The Community Care NC Experience

• Underutilization of controller medications in
  asthmatics and lack of adherence to medications
  in patients with congestive heart failure were
  major contributors to ER visits and
  hospitalizations.
• Dr. Allen Dobson- Former NC Assistant Sec. of
  Health and State Medicaid Director

Informing the Future Critical Issues in Health,
Fourth Edition- Institute of Medicine 2007 pg.
13 http//www.nap.edu/catalog/12014.html
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Group Health Cooperative

• Most patient care interactions involve
  medications and the limitations both in knowledge
  and time on my part make the addition of a
  clinical pharmacist on the medical home team
  MANDATORY ! I would have a difficult time
  maintaining our current standards without this
  person on board.
• James Bergman, M.D. Staff Physician,
• Group Health Permanente, Associate
  Professor,
• Family Medicine, University of Washington,
  Seattle

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Comprehensive Medication Management in the PCMH
Core Principles of the Patient Centered Medical
Home

Elements of Comprehensive Medication Management
ASSESSMENT Reveal the patients medication
experience Identify drug therapy problems in
appropriateness of, effectiveness of, safety of,
and compliance with medications

• CARE PLAN
• Establish personalized goals of therapy
• Resolve drug therapy problems
• Personalize Interventions

FOLLOW-UP Effectiveness and Safety Determine
Actual Patient Outcomes
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Comprehensive Medication Management in the PCMH
Clinical Pharmacist/ Pharmacotherapy Manager
Gaps in clinical goals are determined, drug
therapy problems identified, and therapeutic
recommendations made
Optimal therapeutic recommendations are based on
the experience/needs of the patient

Patient
Physicians/ Providers - PCMH
Appropriate, Effective, Safe and
Adherent Medication Use!
Patient understands his/her medications and
participates in a care plan to improve health
Clinical goals of therapy are determined and
medication recommendations are considered
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Steps to Achieve Comprehensive MTM

• 1) Identify patients that have not achieved
  clinical goals of therapy
• 2) Understand the patients personal medication
  experience/history and preferences/beliefs
• 3) Identify actual use patterns of all
  medications including OTCs, bioactive
  supplements, and prescribed medications
• 4) Systematically review for drug interactions
  then assess each medication for appropriateness,
  effectiveness, safety and adherence (in that
  order) focused on achievement of the clinical
  goals for each therapy

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Steps to Achieve Comprehensive MTM

• 5) Identify all drug therapy problems (the gap
  between current therapy and that needed to
  achieve optimal clinical outcomes)
• 6) Develop a care plan addressing recommended
  steps including therapeutic changes needed to
  achieve optimal outcomes
• 7) Patient agrees with and understands care plan
  which is communicated to the prescriber/provider
  for his/her consent/support

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Steps to Achieve Comprehensive MTM

• 8) Document all steps and current clinical status
  vs. goals of therapy
• 9) Follow-up evaluations with the patient are
  critical to determine effects of changes,
  reassess actual outcomes, and recommend further
  therapeutic changes to achieve desired clinical
  goals/outcomes
• 10) A reiterative process - care is coordinated
  with other team members and personalized (patient
  unique) goals of therapy understood

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Self-insured Employer The Diabetes 10 City
Challenge - Outcomes

• Decrease in A1C (5.2), LDL (32), SBP (15.7),
  DBP (9.2)
• Increase in nutrition, exercise, and weight loss
  goals
• Employer savings of 918 per employee in total
  health care costs
• ROI of at least 41 beginning in the second year
• 50 reduction in absenteeism and fewer workers
  compensation claims
• 97.5 of patients reported being satisfied or
  very satisfied with their diabetes care

• http//www.diabetestencitychallenge.com/
• Fera T, Bluml BM, Ellis WM. Diabetes ten city
  challenge Final economic and clinical results.
  
• JAmPharmAssoc 2009, 49383-91.

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Return on Investment

• Asheville Project - Pharmacist MTM program for
  diabetics saved 1200/pt/yr with improved
  outcomes
• Bunting BA, Cranor CW. The Asheville project
  long term, clinical, humanistic, and economic
  outcomes of a community based medication therapy
  management program for asthma. J Am Pharm. Assoc
  200646133-47.
• Scope of MTM services provided in some
  programs may differ from the comprehensive
  framework described and recommended for the PCMH.
  

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Return on Investment (cont.)

• Minnesota MTM program resolved 3.1 drug therapy
  problems per recipient generating average cost
  savings of approx. 403/pt/yr
• Isetts BJ. Evaluating effectiveness of the
  Minnesota medication therapy management care
  program. Final Report. Available at
  http//www.dhs.state.mn.us/main/groups/business_pa
  rtners/documents/pub/dhs16_140283.pdf.

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Return on Investment (cont)

• On average, 16.70 saved for every 1 invested in
  clinical pharmacy services (review of 104
  studies)
• Bussey HI. Blood, sweat, and tears Wasted by
  Medicares missed opportunities. Pharmacotherapy
  2004241655-58.
• Benefit cost ratio ranged from 1.71 - 17.01
  (literature review).
• Schumock GT, Butler MG, Meek PD, Vermeulen LC,
  Arondekar BV, Bauman JL. 2002 Task Force on
  Economic Evaluation of clinical Pharmacy Services
  of the American College of Clinical Pharmacy.
  Evidence of the economic benefit of clinical
  pharmacy services 1996-2000. Pharmacotherapy.
  2003 Jan, 23(1)113-32.

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Impact of Comprehensive Medication ManagementThe
Patients Perspective

• I have been taking this medication for almost
  seven years. I have never been clear on why I am
  taking it or what it is supposed to do for me,
  and, I have never had anyone who had the time to
  explain it to me. Now I can ask questions and
  discuss my concerns about my medications.
• J.P. (Patient receiving medication
  management services at a medicine clinic in
  Minneapolis, MN)

A thorough understanding of patients illnesses
and how medications impact outcomes is critical
for truly Patient Centered Care.
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Payment for Medication Management Services

• The following recognize and are providing payment
  for the service
• The Federal Government in Medicare Part D
• State Medicaid Governments (for example,
  Minnesota, North Dakota, New York,)
• Employers (e.g., General Mills)
• Commercial plans
• Mechanisms for Payment
• Current Procedural Terminology (CPT) Codes for
  pharmacist-provided MTM services
• Evaluation and Management (EM) CPT Codes
• Capitated Payment Methodologies
• Fee-for-service/Self-pay by patients

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Pharmaceuticals are the most common medical
intervention, and their potential for both help
and harm is enormous. Ensuring that the American
people get the most benefit from advances in
pharmacology is a critical component of improving
the national health care system.The Institute
of Medicine (IOM)1 Drugs Dont Work in People
that Dont Take ThemC. Everett Koop, MDFormer
Surgeon General
1 The Institute of Medicine, National Academy of
Sciences. Informing the future Critical
issues in health. Fourth edition, page 13.
http//www.nap.edu/catalog/12014.html
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Thank You and Join the Collaborative!

• To request any additional information on the
  PCMH or the Patient Centered Primary Care
  Collaborative please contact Edwina Rogers,
  Executive Director
• erogers_at_pcpcc.net, [phone]
• Visit our website http//www.pcpcc.net

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Case Studies
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Community Care of North Carolina

• Focus on improved quality, utilization and cost
  effectiveness of chronic illness care
• 15 Networks with more than 3500 Primary Care
  Physicians (1000 medical homes) and over 950,000
  enrollees

L. Allen Dobson ,Jr. MD FAAFP Former Assistant
Secretary NC Department of Health Human Services
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Community Care of North Carolina

• In 2009 Each Network Now Has
• Part-time paid Medical Director - role is
  oversight of quality efforts, meets with
  practices and serves on State Clinical Committee
• Clinical Coordinator - oversees the overall
  network operations
• Care Managers - small practices share/large
  practices may have their own assigned
• All networks have a pharmacist to assist with
  medication management of high cost patients (MTM)

L. Allen Dobson ,Jr. MD FAAFP Former Assistant
Secretary NC Department of Health Human Services
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North Carolina Medicaid State Fiscal Year 2004
Savings
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North Carolina Clinical Results

• Asthma
• 40 decrease in hospital admission rate
• 16 lower ED rate
• 93 received appropriate maintenance medications
• Diabetes
• 15 increase in quality measures
• Pilots now include the addition of the Aged,
  Blind, and Disabled and Medicare (646 waiver)
  pending!

Source CC_NC 2007 Asthma Disease Management
Program Summary
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The Minnesota MTM experience

• Patients Targeted
• 1 of 12 Chronic Conditions in Adults 18-64 and
• 2 or more health care claims (related to those
  conditions) in the last 12 months
• 285 MTM patients and 252 comparison group all
  BCBS Minnesota health plan members
• Fairview Health System clinics and MTM
  pharmacists
• 6.4 medical conditions and 7.9 drug therapies per
  MTM patient

Isetts, et al. J Am Pharm Assoc.
200848(2)203-211)
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Minnesota MTM Process of Care Overview

• Patient-centered with a clinical pharmacist
• Consistent and systematic process that
• Assessed all of the patients drug-related needs
• Identified drug therapy problems
• Established therapeutic goals
• Designed a medication therapy care plan
• Conducted follow-up visits to evaluate progress
• Communicated information to the patients
  physician or provider
• Linked Medication use to clinical outcome
  improvement

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The Minnesota Experience 637 Drug Therapy
Problems Identified
Needs Additional Drug Therapy 34
Unnecessary Drug Therapy
6 Ineffective Drug 12 Dosage Too Low
20 Adverse Drug Reaction 14 Dosage Too
High 4 Noncompliance 10
100
Indication
Effectiveness
Safety
Compliance
Source Isetts, et al. J Am Pharm Assoc.
200848(2)203-211
32
Economic Outcomes of Minnesota MTMTarget the
Disease, Then Optimize the Drug Therapy

• Total health care cost -31.5
• Facility costs -57.9
• Professional costs -11.1
• Drug costs 19.7

MTM services provided a 121 ROI
Isetts, et al. J Am Pharm Assoc.
200848(2)203-211)
33
Economic Outcomes of MTM Services Summary The
Minnesota Experience

• Total annual health care cost reduced by 31.5
  post MTM from 11,965 to 8,197 (drug costs
  slightly increased with 12 increase in Rx
  claims)
• MTM services delivered and documented by
  Assurance Pharmaceutical Care System generated
  121 ROI

Source Isetts, et al. J Am Pharm Assoc.
200848(2)203-211
34
Clinical Outcomes of Minnesota MTM Services

• Clinical Results Improved!
• Goals of therapy improved from baseline 76 to
  90 after MTM
• 2.2 drug therapy problems per patient identified
  and resolved 78 resolved without MD
• HEDIS Hypertension criteria achieved in 71 of
  MTM patients versus 59 comparison group
• HEDIS Cholesterol criteria achieved in 52 of
  MTM patients versus 30 comparison group

Isetts, et al. J Am Pharm Assoc.
200848(2)203-211)
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Best Practice 1) Targeted Patients with
Chronic Conditions 2) Linked MTM to Clinical
Goals in a team approach
Isetts, et al. J Am Pharm Assoc.
200848(2)203-211)