Transcript Slide 1

The Value of Medication
Therapy Management
Services
ORIGINS AND DEVELOPMENT
OF MTMS
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
…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
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
Pharmacists’ Evolving Role
From Dispensing
Services…
…to a clinical
service provider
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
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
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
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.
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.
ACTIVITIES INCLUDED IN MTMS
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
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
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
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
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
Value of a Personal
Medication Record
“The medication record helps give the doctors a
better picture of what’s going on with me.”
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.”
PHARMACISTS ROLE IN THE
HEALTH CARE TEAM
MTM Pharmacists do not
work in silos….
they are integral members of
the health care team!
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.”
Medication Therapy Management Process
 Today’s wants
and needs
 Responsibility
to participate
in information
sharing and
decision making
 Evaluate appropriateness, effectiveness,
safety, and compliance with medications
 Identify drug therapy problems
CARE PLAN
 Resolve drug therapy problems
 Establish goals of therapy
 Interventions
FOLLOW-UP
 Evaluate progress in meeting goals of
therapy
 Record actual patient outcomes
 Reassess new problems
Experienced Decision Making
Patient
Medication Experience
ASSESSMENT
Practitioner
 Philosophy of Practice
 Social Obligation
 Responsibility to
identify, resolve,
and prevent
drug therapy
problems
 Patient-centered
approach
 Caring
Therapeutic Relationship
MTM Pharmacist/Prescriber
Relationship
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
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
VALUE OF MTMS
American Pharmacists Association
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
EVIDENCE OF THE VALUE OF
MTMS
Studies Illustrating
Value of MTMS
• Asheville Project: Diabetes
• Asheville Project: Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project
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.
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.
Clinical Outcomes of MTMS
The 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
Mean Cost / Patient / Year
Asheville Total Health Care Costs1
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Baseline
1
2
3
4
Follow-up Year
Medical $
Diabetes Rx
Other Rx
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
5
Average Annual Diabetic Sick-Leave Usage
(City of Asheville)
14
12.6
12
10
8.46
8
6
5.68 5.81 5.67 6.01
6
4
2
6
Y
ea
r
5
Y
ea
r
4
Y
ea
r
3
r
Y
ea
r2
Y
ea
1
r
Y
ea
B
as
el
in
e
0
American Pharmacists Association
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
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.
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.
Economic Outcomes of MTMS
The Asheville Project - Asthma
14
12
10
Percentage
% Patients with
ER/Hospital Events
8
6
4
2
0
BY3 BY2 BY1 Y1
Y2
Y3
Y4
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
Y5
Clinical Outcomes of MTMS
The Asheville Project - Asthma
Improved
Asthma control
sustained over 5
years
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
American Pharmacists Association
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)
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.
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 selfmanagement goals
– Recommended changes in therapy when appropriate
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49e52-e60.
10 City Challenge Economic
Outcomes after Year 1
9
8
7
6
Cost in 5
Millions 4
3
2
1
0
Baseline
Year 1
Projected
Year 1
Actual
Medical
Costs
Medication
costs
Pharmacy
Total
Services Health Care
Costs
Costs
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49e52-e60.
10 City Challenge Clinical
Outcomes after Year 1
Percentage of
Participants
100
90
80
70
60
50
40
30
20
10
0
DTCC Baseline
DTCC Year 1
A1C testing
A1C <9%
A1C <7%
Lipid testing
LDL <
BP <130/80 Eye exams Flu vaccine Foot exams
100mg/dL
HEDIS process measures for patients with diabetes
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49e52-e60.
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
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
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
Economic Outcomes from the
Minnesota Experience Project
$12,000
$10,000
1 Year
before
MTM
$8,000
$6,000
1 Year
after
MTM
$4,000
$2,000
$0
Facilities
(-57.9%)
Professional
(-11.1%)
Prescriptions
(+ 19.5%)
Total Cost
(-31.5%)
Clinical Outcomes from the
Minnesota Experience Project
80
% of patients70
meeting 60
HEDIS goals 50
40
30
MTM Group
No MTM
20
10
0
Hypertension
HTN
n = 254;
p=0.03
Dyslipidemia
Dyslipidemia
n = 254;
P=0.001
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
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
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
Summary of evidence of
Value of MTMS
• Economical
– 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.
ELEMENTS OF MTMS
BENEFIT DESIGN
Elements of MTMS Plan Design
• Eligibility
• Reimbursement structure
• Member engagement strategy
– Incentives
Eligibility
• Eligibility for a MTMS benefit can be based on:
– Number of medications
– Specific chronic conditions
– Total amount of prescription expenditures
Reimbursement Structure
• Recommend utilizing the MTMS CPT billing codes
• May used them as defined as time based codes,
or use a cross-walk relative value scale
Example: Minnesota Medicaid
• MHCP will reimburse only for face-to-face encounters
and based on the lowest of five patient need levels,
according to the following qualifying criteria:
– The number of medications the patient is currently taking;
– The number of drug therapy problems the patient has at
present; and
– The number of medical conditions for which the patient is
currently being treated.
• CPT Codes (Time Based Codes)
Based on adopted Minnesota Medicaid law
– 99605
– 99606
– 99607
Example: MN Medicaid Payment
Structure
Level
Assessment of
Drug-related
needs
Identification of Drug
Therapy Problems
1
Problem-focused-at
least 1 medication
Problem-focused 0 drug
therapy problems
Straightforward 1
medical condition
Expanded Problemat least
2 medications
Expanded Problem at
least 1 drug therapy
problem
Straightforward
1 medical condition
2
3
4
5
Detailedat least 3-5
medications
Expanded Detailedat least 6-8
medications
Comprehensive>= 9 medications
Detailed at least 2 drug
therapy problems
Expanded Detailed at
least 3 drug therapy
problems
Comprehensive at least
>4 drug therapy
problems
Complexity-of-Care
Planning & FU
Evaluation
Low complexity at least
2 medical conditions
Moderate Complexity at
least 3 medical
conditions
High Complexity at least
>= 4 medical conditions
Approx.
Face-toFace Time
15 min.
16-30 min.
31-45 min.
46-60 min.
60 + min.
Bill CPT
Code
Units
99605 or
99606
1 unit
99605 or
99606 and
1 unit
99607
1 unit
99605 or
99606 and
1 unit
99607
2 units
99605 or
99606 and
1 unit
99607
3 units
99605 or
99606 and
1 unit;
99607
4 units
Example: Outcomes
Pharmaceutical Health Care
Pharmacist Service
CPT Codes
Comprehensive Medication Review
99605 + 99607
Physician Consultation
99606 + 99607
Patient Compliance Consultation
99606 + 99607
Patient Education/Monitoring
99606
Member Engagement Strategy
• May offer copay reductions or waivers
– For all medications
– For medication associated with a targeted medical
condition (i.e., diabetes)
• Offer reduced copay (or none) for MTMS
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
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
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
• High satisfaction rates among participants