The Value of Medication Therapy Management Services

1
The Value of Medication Therapy Management
Services
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ORIGINS AND DEVELOPMENT OF MTMS
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From Pharmaceutical Care

• Pharmaceutical care is a practice in which the
  practitioner takes responsibility for a patients
  drug-related needs, and is held accountable for
  this commitment.

Cipolle RJ, Strand LM, Morely PC. Pharmaceutical
Care Practice. 1998. McGraw-Hill Companies
4
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

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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
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Pharmacists Evolving Role
From Dispensing Services
to a clinical service provider
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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
8
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
9
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
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Establishment of Billing Codes

• Three (3) 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.
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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.
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ACTIVITIES INCLUDED IN MTMS
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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
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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
15
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
16
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

American Pharmacists Association
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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)

American Pharmacists Association
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Value of a Personal Medication Record

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

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

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

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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

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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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VALUE OF MTMS
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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
•  

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EVIDENCE OF THE VALUE OF MTMS
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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.
33
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.
34
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

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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.
39
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.
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Economic Outcomes of MTMSThe Asheville Project -
Asthma
Bunting BA, Cranor CW. JAPhA. 2006 46133-147.
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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)

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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.
44
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.
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10 City Challenge Economic Outcomes after Year 1
Fera T., Bluml BM, Ellis WM. JAPhA. 2009
49e52-e60.
46
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.
47
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

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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
49
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
50
Economic Outcomes from the Minnesota Experience
Project
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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
52
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

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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 BENEFIT DESIGN
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Elements of MTMS Plan Design

• Eligibility
• Reimbursement structure
• Member engagement strategy
• Incentives

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Eligibility

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

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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

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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

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Example MN Medicaid Payment Structure
Level Assessment of Drug-related needs Identification of Drug Therapy Problems Complexity-of-Care Planning FU Evaluation Approx. Face-to-Face Time Bill CPT Code Units
1 Problem-focused-at least 1 medication Problem-focused 0 drug therapy problems Straightforward 1 medical condition 15 min. 99605 or99606 1 unit
2 Expanded Problem-at least 2 medications Expanded Problem at least 1 drug therapy problem Straightforward 1 medical condition 16-30 min. 99605 or99606 and 1 unit
2 Expanded Problem-at least 2 medications Expanded Problem at least 1 drug therapy problem Straightforward 1 medical condition 16-30 min. 99607 1 unit
3 Detailed-at least 3-5 medications Detailed at least 2 drug therapy problems Low complexity at least 2 medical conditions 31-45 min. 99605 or 99606 and 1 unit
3 Detailed-at least 3-5 medications Detailed at least 2 drug therapy problems Low complexity at least 2 medical conditions 31-45 min. 99607 2 units
4 Expanded Detailed-at least 6-8 medications Expanded Detailed at least 3 drug therapy problems Moderate Complexity at least 3 medical conditions 46-60 min. 99605 or 99606 and 1 unit
4 Expanded Detailed-at least 6-8 medications Expanded Detailed at least 3 drug therapy problems Moderate Complexity at least 3 medical conditions 46-60 min. 99607 3 units
5 Comprehensive- gt 9 medications Comprehensive at least gt4 drug therapy problems High Complexity at least gt 4 medical conditions 60 min. 99605 or 99606 and 1 unit
5 Comprehensive- gt 9 medications Comprehensive at least gt4 drug therapy problems High Complexity at least gt 4 medical conditions 60 min. 99607 4 units
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Example Outcomes Pharmaceutical Health Care
Pharmacist Service CPT Codes
Comprehensive Medication Review 99605 99607
Physician Consultation 99606 99607
Patient Compliance Consultation 99606 99607
Patient Education/Monitoring 99606
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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

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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

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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

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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