The Value of Medication Therapy Management Services

1. The Value of Medication Therapy Management Services

2. ORIGINS AND DEVELOPMENT OF MTMS

3. From Pharmaceutical Care… “Pharmaceutical care is a practice in which the practitioner takes responsibility for a patient’s 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

5. 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

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

7. 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

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

10. 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.

11. 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.

12. ACTIVITIES INCLUDED IN MTMS

13. 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

14. 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

17. 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

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

19. 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.”

20. PHARMACISTS ROLE IN THE HEALTH CARE TEAM

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

22. 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.”

23. 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

24. MTM Pharmacist/Prescriber Relationship

25. 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

26. 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

27. VALUE OF MTMS

28. American Pharmacists Association

29. 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

30. EVIDENCE OF THE VALUE OF MTMS

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

32. 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.

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. 2003;43:173–84.

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. 2003;43:173–84. American Pharmacists Association

35. 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. 2003;43:173-84. American Pharmacists Association

36. Average Annual Diabetic Sick-Leave Usage (City of Asheville) American Pharmacists Association

37. 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

38. 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.

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; 46:133-147.

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

41. Clinical Outcomes of MTMSThe Asheville Project - Asthma Improved Asthma control sustained over 5 years Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147. American Pharmacists Association

42. 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)

43. 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.

45. 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

48. 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

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. 2008;48(2):203-211

50. Economic Outcomes from the Minnesota Experience Project