Medication Therapy Management Jessica Sipe, PharmD Bartell Drugs Community Pharmacy Practice Resident March 1, 2011
Objectives • Define Medication Therapy Management (MTM) • Identify the essential components of MTM • Give real-life examples of MTM services • Explain the importance of pharmacist involvement in MTM services
What is MTM?
What is MTM? • Medication Therapy Management • Services that assure medications are used to • “Optimize therapeutic outcomes through improved medication use” • “Reduce the risk of adverse events, including adverse drug interactions”
Why is MTM needed? • Medication-related problems are a massive public health issue in the U.S. • A 2009 report by NACDS and NCPA found that only half of patients are compliant with their prescription drug regimen • An estimated 1.5 million preventable adverse events occur year • Overall cost of poor medication adherence runs as much as $290 billion per year • 13% of the nation’s total health care expenditures
Where did MTM come from? • MTM is not a new service • Some components are already done daily by most pharmacists • In the 1980s and 1990s, pharmacists began developing a systematic process to assess individual patients’ medication therapies • Pharmacists started to receive reimbursement for these services as early as 1992
Where did MTM come from? • Medicare Prescription Drug Improvement, and Modernization Act of 2003 • Prescription Drug Plans (PDP) must have MTM programs for Medicare Part D medications • The program requires collaboration with a licensed pharmacist or other qualified provider and the patient’s physician(s) • Geared towards specific patients – “targeted beneficiaries” • Ensured that pharmacists received compensation for their services
MTM Participants
Who can benefit from MTM? • Everyone! • Patients who use: • Prescription medications • OTCs • Herbals and other supplements
Who can benefit from MTM? • Patients who may benefit the most: • On several medications • With several health conditions • Who have questions or problems with their medications • Taking medications that require close monitoring • Have been recently hospitalized • Obtain their medications from more than one pharmacy
Who is eligible for MTM Services? • Anyone who wants to pay out of pocket • Anyone whose prescription drug plan (PDP) will pay for it • In Medicare terms, these patients are “targeted beneficiaries” • Often these patients will be identified for you
Current Targeted Beneficiary Requirements • Must have multiple chronic diseases • PDP cannot require more than 3 chronic diseases • PDP can choose to accept any chronic diseases or limit enrollment to specific diseases, but must target at least four of these conditions: • Hypertension • Heart failure • Diabetes • Dyslipidemia • Respiratory disease • Bone disease/arthritis • Mental health
Current Targeted Beneficiary Requirements, cont’d • Must take “multiple” Part D medications • PDP cannot require more than 8 medications as the minimum • “High” drug costs • Before 2009: patients had to be predicted to spend at least $4000 on medications • 2010 and beyond: patients have to be predicted to spend at least $3000 on medications • 12.9% of Medicare Part D members were eligible in 2010.
Activities that could be considered MTM services • Performing or obtaining necessary assessments of the patient’s health status • Formulating a medication treatment plan • Selecting, initiating, modifying, or administering medication therapy • Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness • Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events
Activities that could be considered MTM services • Documenting the care delivered and communicating essential information to the patient’s other primary care providers • Providing verbal education and training designed to enhance patient understanding and appropriate use of his/her medications • Providing information, support services and resources designed to enhance patient adherence with his/her therapeutic regimens • Coordinating and integrating medication therapy management services within the broader health care-management services being provided to the patient
Questions so far?
Providing MTM • Setting • Institutional • Ambulatory/community • Two types of MTM • Point-of-care • Comprehensive Medication Review • Payment for services is ideally based on the time, clinical intensity and resources required to perform the services
What happens during an MTM Service?
Point-of-Care MTM • Typically related to a specific medication product • Involves identifying potential problems during the normal workflow of the pharmacy (i.e. at the “point of care”) • Interventions are on-going and may occur at any time • Examples: • Formulary management • Monitoring medication compliance • Assessing need for new care • Providing patient education on new medication with follow-up
Comprehensive Medication Review • Patient-focused interview between the patient and the pharmacist • Review all medications (prescription, OTC, herbal, supplements) • Identify, resolve, and prevent medication-related problems • Improve medication therapy and disease management • Must be offered yearly to all targeted beneficiaries • 3 parts: • Pre-work-up • Patient Interview/Consultation • Follow-up
Pre-Work-Up • Initial review of medications (preparing for the consultation): • Drug Interactions • Cost-saving opportunities • Therapeutic Duplication/Suboptimal therapy • Appropriateness of therapy • Over-use/Under-use of medications • Insufficient/Excessive dosing • Lab Assessment
Poly-Med Guide • List of patient’s medications sorted by disease state • Drug, strength, and quantity prescribed • Directions • Refill history • Comments/Questions/Concerns • Counseling points • Side effects • Efficacy of therapy • Monitoring • Compliance/Frequency of use • Cost-savings opportunities • Administration/technique
Consultation • Face-to-face or by telephone • Face-to-face interaction is preferred • Clarify allergies and medical conditions • Assess • Medication use/adherence • Side effects and efficacy • Goals of therapy and progress • Understanding of medication therapy • Administration technique
Consultation • Other issues to assess and address • Patient’s healthcare priorities • Cost • Comfort • Minimizing side effects • Convenience • Simplifying therapy • Language barriers • Literacy level • Cultural Issues
Follow-up • Provider • Document care provided • Collaborate with provider to find solutions to medication therapy issues • Patient • Provide master medication list • Propose a medication action plan to: • Address identified problems • Maintain self-management efficacy • Assess improvement/decline in therapy • Address additional questions/concerns
Any Questions So Far?
MTM Platforms • For billing and documentation • May also help assess medication problems • Generally internet-based • MirixaPro™ • Face-to-face CMR; $100 • Telephone CMR; $60 • Flat-fee reimbursement only • Outcomes Pharmaceutical Health Care™ • CMR (face-to-face only); $50 • Can bill for subsequent claims resulting from CMR
OutcomesTMClassification of Pharmacist Interventions Compliance Assessment Overuse Underuse Admin/Technique Cost Efficacy Management New/Change Prescription or OTC Therapy Other • Drug Therapy Problems • Indications • Needs Therapy • Unnecessary Therapy • Efficacy • Suboptimal Drug Selection • Insufficient Dose/Duration • Safety • Adverse Drug Reaction • Drug Interaction • Excessive Dose/Duration
OutcomesTMClassification of Results Compliance Assessment Altered Compliance Altered Admin/Technique Cost Efficacy Management Initiated Cost Effective Drug New/Change Prescription or OTC Therapy Therapeutic Success Therapeutic Failure Other • Drug Therapy Problems • Indications • Initiated Therapy • Discontinued Therapy • Efficacy • Changed Drug • Increased Dose/Duration • Safety • Altered Regimen/Change Drug • Decreased Dose/Duration Patient refusal or prescriber refusal are also potential results of pharmacist interventions
OutcomesTM Billing: ECA levels • The significance of MTM services is reported to OutcomesTM via estimated cost avoidance (ECA) levels. • Justification must be provided by the pharmacist • The claim is reviewed to be sure that the ECA level is reasonable. • Each ECA level has an associated ECA dollar amount tied it which approximates the cost of future pharmaceutical, medical, and/or hospital-related costs that would have likely resulted had the MTM intervention not taken place. • Based on a cost of illness model & updated annually for inflation.
OutcomesTM Billing: ECA levels • Refusal: Patient/Prescriber Refusal • Level 1: Improved Quality of Care • Level 2: Drug Product Costs • Level 3: Additional Physician Visit • Level 4: Additional Prescription Order • Level 5: Emergency Room Visit • Level 6: Hospital Admission • Level 7: Life Threatening
Where is MTM going? • The Medication Therapy Management Empowerment Act of 2011 • Would increase the number of seniors eligible under Medicare Part D for MTM services • Patients would only need one chronic condition, such as heart disease, to be a targeted beneficiary • Introduced by Sen. Kay Hagan (D, NC) and co-sponsored by Sens. Al Franken (D, MN), Sherrod Brown (D, OH) and Tim Johnson (D, SD) • Introduced on Feb 3, 2011 and referred to the Senate Finance Committee
Where is MTM going? • Many leaders in pharmacy circles see MTM as the future of the profession • But pharmacists need to make time for it and integrate MTM into their everyday activities • Where ever you take it – get involved! • Participate in student legislative days • Get involved in pharmacy organizations at the local, state and national level • Prove to patients, physicians and other providers that pharmacists are the best-equipped to offer MTM services
Conclusions • MTM is an important tool to optimize therapeutic outcomes • It’s important for pharmacists to take advantage of opportunities to provide MTM • Use your clinical skills • Get valued for your expertise • Get recognized and paid for your services
Additional MTM Resources • American Pharmacists Association: • www.pharmacist.com MTM Central • UW Pharmacy Cares: • sop.washington.edu/pharmacy-cares • Association of Managed Care Pharmacists: • www.amcp.org/amcp.ark?p=2FEF7BCF • Center for Medicare & Medicare Services: • www.cms.gov/prescriptiondrugcovcontra/082_mtm.asp • Washington State Pharmacy Association: • www.wsparx.org
Pre-lab • MTM Activity • Pass/Redo • Assess patient eligibility for MTM • Complete a CMR for a patient • Work-up with poly-med guide • Patient interview and consultation • Follow-up with patient • No Homework!
Questions?
