The Value of Medication Therapy Management Services

1. The Value of Medication Therapy Management Services

2. ORIGINS AND DEVELOPMENT OF MTMS

3. 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.

4. 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.

5. 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”

6. 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”

7. 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.

8. …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

9. 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

10. Pharmacists’ Evolving Role From Dispensing Services… …to a clinical service provider

11. 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 . Bluml BM. Definition of medication therapy management: development of professionwide consensus. J Am Pharm Assoc. 2005;45:566–72

12. 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

13. 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

14. 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. Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009. American Medical Association: Chicago, IL.

15. 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.  CPT Code Definition of MTMS • Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009. American Medical Association: Chicago, IL.

16. ACTIVITIES INCLUDED IN MTMS

17. 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

18. 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

19. 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

20. 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

21. 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) APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

22. Value of a Personal Medication Record “The medication record helps give the doctors a better picture of what’s going on with me.”

23. Value of MTMS “Having the help of a person who specializes in medications, which impacts me on a daily basis—putting drugs in my body.”

24. PHARMACISTS ROLE IN THE HEALTH CARE TEAM

25. they are integral members of the health care team! Pharmacists do not work in silos….

26. Physicians Value Pharmacists “Working with the pharmacist has helped me to focus on the things that only I can do as a physician.”

27. Medication Therapy Management Process ASSESSMENT  Evaluate appropriateness, effectiveness, safety, and compliance with medications  Identify drug therapy problems Patient Practitioner 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  Today’s 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

28. Pharmacist/Prescriber Relationship

29. 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

30. 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

31. VALUE OF MTMS

32. APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

33. 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

34. EVIDENCE OF THE VALUE OF MTMS

35. Studies Illustrating Value of MTMS Asheville Project: Diabetes Asheville Project: Asthma Diabetes Ten City Challenge Minnesota Experience Project

36. 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.

37. 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.

38. Clinical Outcomes of MTMSThe Asheville Project - Diabetes 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

39. Asheville Total Health Care Costs1 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

40. Average Annual Diabetic Sick-Leave Usage (City of Asheville) APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

41. 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.

42. 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.

43. 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.

44. Economic Outcomes of MTMSThe Asheville Project - Asthma Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

45. Clinical Outcomes of MTMSThe Asheville Project - Asthma Improved Asthma control sustained over 5 years 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

46. 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.

47. 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.

48. 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; 49(3): 383-391.

49. 10 City Challenge Economic Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

50. 10 City Challenge Clinical Outcomes after Year 1 HEDIS process measures for patients with diabetes Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.