Transcript Slide 1

The Value of Medication
Therapy Management Services
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ORIGINS AND DEVELOPMENT
OF MTMS
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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
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…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
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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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
Pharmacists’ Evolving Role
From Dispensing
Services…
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…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
.
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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
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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
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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.
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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.
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Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009.
American Medical Association: Chicago, IL.
ACTIVITIES INCLUDED IN MTMS
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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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
–
–
–
–
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Immunizations
Wellness screenings
Smoking cessation
Weight management
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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)
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
Value of a Personal
Medication Record
“The medication record helps give the doctors a
better picture of what’s going on with me.”
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Value of MTMS
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“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
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Pharmacists do not work in
silos….
they are integral members of the
health care team!
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Physicians Value Pharmacists
“Working with the pharmacist has helped me to focus on
the things that only I can do as a physician.”
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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
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Therapeutic Relationship
Pharmacist/Prescriber Relationship
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Pharmacist’s Communication
with other Health Providers
• 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
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Medications Recommendations
• 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
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VALUE OF MTMS
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APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
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EVIDENCE OF THE VALUE OF MTMS
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Studies Illustrating
Value of MTMS
• Asheville Project: Diabetes
• Asheville Project: Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project
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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
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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
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Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173–84.
Clinical Outcomes of MTMS
The Asheville Project - Diabetes
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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.
APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants.
Available at: www.pharmacist.com
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 $
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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.
APhA. Pharmacists Improving Care and Reducing Costs for Your Plan
Participants. Available at: www.pharmacist.com
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
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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
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
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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
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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
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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
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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
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Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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ELEMENTS OF MTMS
BENEFIT DESIGN
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Elements of MTMS Plan Design
• Eligibility
• Reimbursement structure
• Member engagement
strategy
– Incentives
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Eligibility
• Eligibility for a MTMS benefit can be based on:
– Number of medications
– Specific chronic conditions
– Total amount of prescription expenditures
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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
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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
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– 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
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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
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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
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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
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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
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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
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