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

8. 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.”

9. 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.”

10. 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

11. MTM Pharmacist/Prescriber Relationship

12. 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

13. American Pharmacists Association

14. 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

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

16. Asheville Project: Diabetes • Evaluation of outcomes following community based provision of MTMS to patients with diabetes covered by a self-insured employer group (City of Asheville, NC and Mission-St. Joseph’s Health System) • 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.

17. Key Findings: Asheville Diabetes • Economic benefit • Total health care costs for patients decreased (after 5 years, an average of $3,356 per patient per month savings) • Prescription costs increased, but medical costs decreased • Clinical benefit • Significant improvement seen in A1C (7.6% baseline vs. 6.2% after 14 months, p<0.05) and LDL (118mg/dl baseline vs. 98mg/dl after 14 months, p<0.05) • Humanistic benefit • Decreased sick leave; increased worker productivity Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84.

18. Asheville Project: Asthma • Evaluation of outcomes following community based provision of MTMS to patients with asthma covered by a self-insured employer group (City of Asheville, NC and Mission-St. Joseph’s Health System) • 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.

19. Key Findings: Asheville Asthma • Economic benefit • Decreased percentage of asthma patients requiring emergency (9.9% to 1.3%) and hospital care (4.0% to 1.9%) • An average decrease in costs of $725/patient/year • Clinical benefit • Improved asthma control sustained over 5 years (as evidenced by FEV1 measurements) Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

20. 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.

21. Key Findings: 10 City Challenge • Economic benefit • Total health care costs were less than predicted (7.24% 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.

22. 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

23. 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

24. 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

25. 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 improvement 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.

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

27. Eligibility • Eligibility for a MTMS benefit can be based on: • Number of medications • Specific chronic conditions • Total amount of prescription expenditures • Disease state quality goals

28. 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

29. 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.

30. 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.

31. Member Engagement Strategy • May offer copay reductions or waivers • For all medications • For medications associated with a targeted medical condition (i.e. diabetes, hypertension, dyslipidemia) • Copay waivers for targeted medications and supplies were included in the results of the Asheville Study examples and the Diabetes Ten City Challenge • Offer reduced copay (or none) for MTMS • Copay waivers for the pharmacist visit were included in the results of the Asheville Study examples and the Diabetes Ten City Challenge 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.

32. 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

33. What’s In It For the Patient? • MTMS provides patients with improved health outcomes from optimizing medication use • This includes decreased emergency department visits and hospitalizations • Increased understanding of medications and disease management • Improved quality of life

34. 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