The Value of Medication Therapy Management Services

1. The Value of Medication Therapy Management Services

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. MTM Pharmacist/Prescriber Relationship

9. 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

10. 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

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

12. 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

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

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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.

20. 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.

21. 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.

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

23. 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

24. 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.

25. 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.

26. 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.

27. 10 City Challenge Economic Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

28. 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.

29. 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.

30. 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

31. 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

32. Economic Outcomes from the Minnesota Experience Project

33. Clinical Outcomes from the Minnesota Experience Project HTN n = 254; p=0.03 Dyslipidemia n = 254; P=0.001 Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

34. 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

35. 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

36. 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.

37. Elements of MTMS Plan Design • Eligibility • Reimbursement structure • Member engagement strategy • Incentives

38. 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

39. 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

40. 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

41. 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