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The Value of Medication
Therapy Management
Services
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
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 patient’s other health care providers
.
Bluml BM. Definition of medication therapy management: development of
professionwide consensus. J Am Pharm Assoc. 2005;45:566–72
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
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
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
Medication Therapy Management Process
Today’s wants
and needs
Responsibility
to participate
in information
sharing and
decision making
Evaluate appropriateness, effectiveness,
safety, and compliance with medications
Identify drug therapy problems
CARE PLAN
Resolve drug therapy problems
Establish goals of therapy
Interventions
FOLLOW-UP
Evaluate progress in meeting goals of
therapy
Record actual patient outcomes
Reassess new problems
Experienced Decision Making
Patient
Medication Experience
ASSESSMENT
Practitioner
Philosophy of Practice
Social Obligation
Responsibility to
identify, resolve,
and prevent
drug therapy
problems
Patient-centered
approach
Caring
Therapeutic Relationship
MTM Pharmacist/Prescriber
Relationship
Pharmacist’s Communication
with other Health Providers
• MTM Pharmacists will communicate regularly with
patient’s primary care provider, and other health care
team members as appropriate
– Describe assessment
– Describe and rationalize recommendations for medication
changes
– Recommendations for follow-up
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
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
Studies Illustrating
Value of MTMS
• Asheville Project: Diabetes
• Asheville Project: Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project
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. 2003;43:173–84.
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. 2003;43:173–84.
Clinical Outcomes of MTMS
The 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. 2003;43:173–84.
American Pharmacists Association
Mean Cost / Patient / Year
Asheville Total Health Care Costs1
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Baseline
1
2
3
4
Follow-up Year
Medical $
Diabetes Rx
Other Rx
Cranor CW, Bunting BA, Christensen DB.. J Am Pharm Assoc. 2003;43:173-84.
APhA. Pharmacists Improving Care and Reducing Costs for Your Plan
Participants. Available at: www.pharmacist.com
5
Average Annual Diabetic Sick-Leave Usage
(City of Asheville)
14
12.6
12
10
8.46
8
6
5.68 5.81 5.67 6.01
6
4
2
6
Y
ea
r
5
Y
ea
r
4
Y
ea
r
3
r
Y
ea
r2
Y
ea
1
r
Y
ea
B
as
el
in
e
0
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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. 2003;43:173-84.
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; 46:133-147.
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; 46:133-147.
Economic Outcomes of MTMS
The Asheville Project - Asthma
14
12
10
Percentage
% Patients with
ER/Hospital Events
8
6
4
2
0
BY3 BY2 BY1 Y1
Y2
Y3
Y4
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
Y5
Clinical Outcomes of MTMS
The Asheville Project - Asthma
Improved
Asthma control
sustained over 5
years
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
American Pharmacists Association
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; 46:133-147.
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.
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 selfmanagement goals
– Recommended changes in therapy when appropriate
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
10 City Challenge Economic
Outcomes after Year 1
9
8
7
6
Cost in 5
Millions 4
3
2
1
0
Baseline
Year 1
Projected
Year 1
Actual
Medical
Costs
Medication
costs
Pharmacy
Total
Services Health Care
Costs
Costs
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
10 City Challenge Clinical
Outcomes after Year 1
Percentage of
Participants
100
90
80
70
60
50
40
30
20
10
0
DTCC Baseline
DTCC Year 1
A1C testing
A1C <9%
A1C <7%
Lipid testing
LDL <
BP <130/80 Eye exams Flu vaccine Foot exams
100mg/dL
HEDIS process measures for patients with diabetes
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
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.
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 12:1
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
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. 2008;48(2):203-211
Economic Outcomes from the
Minnesota Experience Project
$12,000
$10,000
1 Year
before
MTM
$8,000
$6,000
1 Year
after
MTM
$4,000
$2,000
$0
Facilities
(-57.9%)
Professional
(-11.1%)
Prescriptions
(+ 19.5%)
Total Cost
(-31.5%)
Clinical Outcomes from the
Minnesota Experience Project
80
% of patients70
meeting 60
HEDIS goals 50
40
30
MTM Group
No MTM
20
10
0
Hypertension
HTN
n = 254;
p=0.03
Dyslipidemia
Dyslipidemia
n = 254;
P=0.001
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
Key Findings:
Minnesota Experience Project
• Economic benefit
– A 12:1 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
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
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
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. 2008;48(2):203-211
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84.
Elements of MTMS Plan Design
• Eligibility
• Reimbursement structure
• Member engagement strategy
– Incentives
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
What’s 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
What’s 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
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