Transcript Slide 1

The Value of Medication
Therapy Management Services
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ORIGINS AND DEVELOPMENT
OF MTMS
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Milestones in the Evolution of the
Pharmacist as a Clinician
1949 – The Elliott Commission recommends that
pharmaceutical education move toward a doctor of
pharmacy degree.
1973 – APhA endorses the concept of “clinical pharmacy”
in practice.
1975 – The Millis Commission recommends more clinical
education and courses in social and behavioral sciences to
recognize pharmacists’ growing patient care roles.
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Milestones in the Evolution of the
Pharmacist as a Clinician
1990 – Hepler and Strand propose the concept of
‘Pharmaceutical Care’
“Pharmaceutical care is the responsible provision of drug
therapy for the purpose of achieving definite outcomes that
improve a patient’s quality of life”
1990 – OBRA ’90 requires pharmacists to perform DUR
and to offer to counsel Medicaid patients; most states
eventually extend these requirements to all patients.
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Milestones in the Evolution of the
Pharmacist as a Clinician
1991 – APhA proposes Pharmacy’s mission:
“The mission of Pharmacy is to serve society as the
profession responsible for the appropriate use of
medications, devices and services to achieve optimal
therapeutic outcomes”
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Milestones in the Evolution of the
Pharmacist as a Clinician
1993 – NCPA proposes the concept of ‘Pharmacist Care’
“Pharmacist Care is a comprehensive approach to
pharmacist-directed patient care management through
which pharmacists provide an expanded level of patient
care that focuses on disease prevention and wellness
programs and includes monitoring, evaluating, counseling,
intervening and directing medication-related therapies to
enhance patient care and improve health outcomes”
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Milestones in the Evolution of the
Pharmacist as a Clinician
2003 – Medicare Modernization Act (MMA) is passed;
creates an outpatient prescription drug benefit for
Medicare recipients. The MMA recognizes patients’ need
for medication therapy management services (MTMS) and
the role of pharmacists as providers of MTMS.
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…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 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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
Pharmacists’ Evolving Role
From Dispensing
Services…
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…to a clinical
service provider
Pharmacy’s 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
.
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Bluml BM. Definition of medication therapy management: development of
professionwide consensus. J Am Pharm Assoc. 2005;45:566–72
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
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www.cms.hhs.gov
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
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www.cms.hhs.gov
Establishment of Billing Codes
• Three ‘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.
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Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009.
American Medical Association: Chicago, IL.
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.
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Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009.
American Medical Association: Chicago, IL.
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
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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
–
–
–
–
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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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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)
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
Value of a Personal
Medication Record
“The medication record helps give the doctors a
better picture of what’s going on with me.”
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Value of MTMS
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“Having the help of a person who
specializes in medications, which
impacts me on a daily basis—putting
drugs in my body.”
PHARMACISTS ROLE IN THE
HEALTH CARE TEAM
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Pharmacists do not work in
silos….
they are integral members of the
health care team!
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Physicians Value Pharmacists
“Working with the 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
 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
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Therapeutic Relationship
Pharmacist/Prescriber Relationship
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Pharmacist’s Communication
with other Health Providers
• 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
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Medication Recommendations
• 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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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
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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
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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
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Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173–84.
Clinical Outcomes of MTMS
The Asheville Project - Diabetes
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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
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 $
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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
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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
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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
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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
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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
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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
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Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
$8,197
• 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
• 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.
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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
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 use 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
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– 99605
– 99606
– 99607
Example: MN Medicaid Payment
Structure
Level
Assessment of
Drug-related
needs
Identification of Drug
Therapy Problems
1
Problem-focused-at
least 1 medication
Problem-focused 0 drug
therapy problems
Straightforward 1
medical condition
Expanded Problemat least
2 medications
Expanded Problem at
least 1 drug therapy
problem
Straightforward
1 medical condition
2
3
4
5
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Detailedat least 3-5
medications
Expanded Detailedat least 6-8
medications
Comprehensive>= 9 medications
Detailed at least 2 drug
therapy problems
Expanded Detailed at
least 3 drug therapy
problems
Comprehensive at least
>4 drug therapy
problems
Complexity-of-Care
Planning & FU
Evaluation
Low complexity at least
2 medical conditions
Moderate Complexity at
least 3 medical
conditions
High Complexity at least
>= 4 medical conditions
Approx.
Face-toFace Time
15 min.
16-30 min.
31-45 min.
46-60 min.
60 + min.
Bill CPT
Code
Units
99605 or
99606
1 unit
99605 or
99606 and
1 unit
99607
1 unit
99605 or
99606 and
1 unit
99607
2 units
99605 or
99606 and
1 unit
99607
3 units
99605 or
99606 and
1 unit;
99607
4 units
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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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
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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
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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
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