Transcript MTM in PCMH

The Opportunity for
Comprehensive Medication Management
Presenter Name
Agenda
• The Need for Medication Management Services
• The PCMH Team as a Solution
• The Steps of Comprehensive Medication
Management
• Impact of the Service
• Payment Approaches
• Case Studies
The Facts
• 75% of all healthcare costs are related to
chronic disease
• After lifestyle interventions, medications are the
primary weapons used in modern medicine to
prevent disease and effectively control chronic
disease
• Proper use of medications can lead to
improved health, enhanced quality of life, and
increased productivity when directly linked to
clinical outcome goals.
So Why A Quality Gap?
The Facts
• Four out of Five patients leave with at least one prescription1
• One-third of all American adults take 5 or more medications
• Medicare beneficiaries with multiple illnesses:
• See an average of 13 different physicians
• Have 50 different prescriptions filled each year
• Account for 76% of all hospital admissions
• Account for 88% of all prescriptions filled
• Account for 72% of physician visits
• Are 100 times more likely to have a preventable
hospitalization than someone without a chronic
condition2
1 The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001 2 Testimony of Gerard F. Anderson, Ph.D.,
Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging,
2 “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007)
HealthCare Landscape
But what happens to those prescriptions?
35%
30%
30%
26%
25%
Non-Compliant Behaviors
21%
18%
20%
14%
15%
10%
5%
0%
took less often
stopped sooner
smaller doses
delayed fill
failed to fill
The Hidden Epidemic: Finding a Cure for
Unfilled Prescriptions and Missed Doses.
December, 2003. The Boston Consulting
Group and Harris Interactive. Available at
http://www.bcg.com/publications/files/TheH
iddenEpidemic_Rpt_HCDec03.pdf.
Accessed August 16, 2004.
Why Didn’t They Take Their Medication?
• 24% forgetfulness
• 20% undesirable or debilitating side effects
• 17% medication was too costly
• 14% decided they didn't need the drug
• 10% difficulties in getting the prescription filled
The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses, December, 2003. The Boston Consulting
Group and Harris Interactive. Available at http://www.bcg.com/publications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf.
Accessed August 16, 2004.
The PCMH Team Closes The Quality Gap
Appropriate medications need to be recommended
and prescribed,
Patients need to thoroughly understand, have
access to, and engage with their medications
The most effective treatments (with continual
evaluation & modification) can produce optimal
clinical and quality outcomes.
Why Is Medication Management Needed
in the PCMH?
• Comprehensive medication management has
been shown to facilitate the efficiency and
effectiveness of the PCMH team in improving
patient clinical outcomes, reducing morbidity
and mortality, while lowering total healthcare
costs.
• Medication Management is even more essential
when multiple providers/prescribers are
involved with complex patients
The Community Care NC Experience
“Underutilization of controller medications in
asthmatics and lack of adherence to medications
in patients with congestive heart failure were
major contributors to ER visits and
hospitalizations.”
Dr. Allen Dobson- Former NC Assistant Sec. of Health and State
Medicaid Director
Informing the Future: Critical Issues in Health, Fourth Edition- Institute of Medicine 2007 pg. 13 http://www.nap.edu/catalog/12014.html
Group Health Cooperative
“Most patient care interactions involve medications
and the limitations both in knowledge and time on my part
make the addition of a clinical pharmacist on the medical
home team MANDATORY ! I would have a difficult time
maintaining our current standards without this person on
board.”
James Bergman, M.D. – Staff Physician,
Group Health Permanente, Associate Professor,
Family Medicine, University of Washington, Seattle
Comprehensive Medication Management
in the PCMH
Elements of Comprehensive
Medication Management
ASSESSMENT
Core Principles of the Patient
Centered Medical Home
Reveal the patient’s medication
experience
Identify drug therapy problems in
appropriateness of, effectiveness of,
safety of, and compliance with
medications
Personal
Team
Relationship
Approach
Value
Comprehensive
CARE PLAN
Establish personalized goals of
therapy
Resolve drug therapy problems
Personalize Interventions
FOLLOW-UP
Effectiveness and Safety
Determine Actual Patient
Outcomes
Access
Coordinated
Quality
Safety
Comprehensive Medication Management in the PCMH
Gaps in clinical goals are
determined, drug therapy
problems identified, and
therapeutic
recommendations made
Clinical Pharmacist/
Pharmacotherapy Manager
Optimal therapeutic
recommendations are
based on the
experience/needs of the
patient
Patient
Appropriate, Effective,
Safe and Adherent
Medication Use!
Patient understands his/her medications
and participates in a care plan to
improve health
Physicians/
Providers - PCMH
Clinical goals of therapy are
determined and medication
recommendations are considered
Steps to Achieve Comprehensive MTM
1) Identify patients that have not achieved clinical goals of therapy
2) Understand the patient’s personal medication
experience/history and preferences/beliefs
3) Identify actual use patterns of all medications including OTCs,
bioactive supplements, and prescribed medications
4) Systematically review for drug interactions then assess each
medication for appropriateness, effectiveness, safety and
adherence (in that order) focused on achievement of the clinical
goals for each therapy
Steps to Achieve Comprehensive MTM
5) Identify all drug therapy problems (the gap between
current therapy and that needed to achieve optimal
clinical outcomes)
6) Develop a care plan addressing recommended steps
including therapeutic changes needed to achieve
optimal outcomes
7) Patient agrees with and understands care plan which is
communicated to the prescriber/provider for his/her
consent/support
Steps to Achieve Comprehensive MTM
8) Document all steps and current clinical status vs. goals
of therapy
9) Follow-up evaluations with the patient are critical to
determine effects of changes, reassess actual
outcomes, and recommend further therapeutic changes
to achieve desired clinical goals/outcomes
10) A reiterative process - care is coordinated with other
team members and personalized (patient unique) goals
of therapy understood
Self-insured Employer: The Diabetes 10
City Challenge - Outcomes
– Decrease in A1C (5.2%), LDL (32%), SBP (15.7%), DBP
(9.2%)
– Increase in nutrition, exercise, and weight loss goals
– Employer savings of ~$918 per employee in total health
care costs
– ROI of at least 4:1 beginning in the second year
– 50% reduction in absenteeism and fewer workers’
compensation claims
– 97.5% of patients reported being satisfied or very satisfied
with their diabetes care
1.
2.
http://www.diabetestencitychallenge.com/
Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: Final economic and clinical results.
JAmPharmAssoc 2009, 49:383-91.
Return on Investment
• Asheville Project ** - Pharmacist MTM program for
diabetics saved $1200/pt/yr with improved outcomes
Bunting BA, Cranor CW. The Asheville project: long term, clinical, humanistic,
and economic outcomes of a community based medication therapy management
program for asthma. J Am Pharm. Assoc 2006;46:133-47.
** Scope of MTM services provided in some programs may differ from the
comprehensive framework described and recommended for the PCMH.
Return on Investment (cont.)
• Minnesota MTM program resolved 3.1 drug
therapy problems per recipient generating average
cost savings of approx. $403/pt/yr
Isetts BJ. Evaluating effectiveness of the Minnesota medication therapy management
care program. Final Report. Available at:
http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs16_1402
83.pdf.
Return on Investment (cont)
• On average, $16.70 saved for every $1 invested in
clinical pharmacy services (review of 104 studies)
Bussey HI. Blood, sweat, and tears: Wasted by Medicare’s missed opportunities.
Pharmacotherapy 2004;24:1655-58.
• Benefit: cost ratio ranged from 1.7:1 - 17.0:1
(literature review).
Schumock GT, Butler MG, Meek PD, Vermeulen LC, Arondekar BV, Bauman JL. 2002 Task
Force on Economic Evaluation of clinical Pharmacy Services of the American College of
Clinical Pharmacy. Evidence of the economic benefit of clinical pharmacy services: 19962000. Pharmacotherapy. 2003 Jan, 23(1):113-32.
Impact of Comprehensive Medication
Management
The Patient’s Perspective
“I have been taking this medication for almost
seven years. I have never been clear on why I am taking it
or what it is supposed to do for me, and, I have never had
anyone who had the time to explain it to me. Now I can ask
questions and discuss my concerns about my
medications.”
J.P. (Patient receiving medication
management services at a medicine clinic in Minneapolis, MN)
A thorough understanding of patients’ illnesses
and how medications impact outcomes is critical for truly
Patient Centered Care.
Payment for Medication Management Services
The following recognize and are providing payment for the
service:
• The Federal Government in Medicare Part D
• State Medicaid Governments (for example,
Minnesota, North Dakota, New York,)
• Employers (e.g., General Mills)
• Commercial plans
Mechanisms for Payment
• Current Procedural Terminology (CPT) Codes for
pharmacist-provided MTM services
• Evaluation and Management (E&M) CPT Codes
• Capitated Payment Methodologies
• Fee-for-service/Self-pay by patients
21
“Pharmaceuticals are the most common medical
intervention, and their potential for both help and harm
is enormous. Ensuring that the American people get
the most benefit from advances in pharmacology is a
critical component of improving the national health care
system.”
The Institute of Medicine (IOM)1
“Drugs Don’t Work in People that Don’t Take Them”
C. Everett Koop, MD
Former Surgeon General
1 The Institute of Medicine, National Academy of Sciences. Informing the future: Critical issues in health. Fourth edition, page 13.
http://www.nap.edu/catalog/12014.html
22
Thank You and Join the Collaborative!
To request any additional information on the PCMH or the
Patient Centered Primary Care Collaborative please contact
Edwina Rogers, Executive Director:
[email protected], (202)724-3331
Visit our website – http://www.pcpcc.net
Case Studies
24
Community Care of North Carolina
 Focus on improved quality, utilization and cost
effectiveness of chronic illness care
 15 Networks with more than 3500 Primary Care
Physicians (1000 medical homes) and over
950,000 enrollees
L. Allen Dobson ,Jr. MD FAAFP Former Assistant Secretary NC Department of Health &Human Services
Community Care of North Carolina
In 2009 Each Network Now Has:
• Part-time paid Medical Director - role is oversight of
quality efforts, meets with practices and serves on State
Clinical Committee
• Clinical Coordinator - oversees the overall network
operations
• Care Managers - small practices share/large practices
may have their own assigned
• All networks have a pharmacist to assist with medication
management of high cost patients (MTM)
L. Allen Dobson ,Jr. MD FAAFP Former Assistant Secretary NC Department of Health &Human Services
North Carolina Medicaid State Fiscal Year 2004 Savings
Category of Service
Inpatient
Outpatient
Emergency Room
Primary Care, Specialist
Pharmacy
Other
Totals
Estimated Savings from
Benchmark
$142,085,680
$51,865,028
$25,944,553
$45,498,709
$(15,526,996)
$(5,065,238)
$244,801,735
North Carolina Clinical Results
Asthma
– 40% decrease in hospital admission rate
– 16% lower ED rate
– 93% received appropriate maintenance medications
Diabetes
– 15% increase in quality measures
Pilots now include the addition of the Aged, Blind, and
Disabled and Medicare (646 waiver) pending!
Source: CC_NC 2007 Asthma Disease Management Program Summary
The Minnesota MTM experience
Patients Targeted
– 1 of 12 Chronic Conditions in Adults 18-64 and
– 2 or more health care claims (related to those
conditions) in the last 12 months
• 285 MTM patients and 252 comparison group – all
BCBS Minnesota health plan members
– Fairview Health System clinics and MTM pharmacists
– 6.4 medical conditions and 7.9 drug therapies per MTM
patient
Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211)
Minnesota MTM Process of Care
Overview
• Patient-centered with a clinical pharmacist
• Consistent and systematic process that:
– Assessed all of the patient’s drug-related needs
– Identified drug therapy problems
– Established therapeutic goals
– Designed a medication therapy care plan
– Conducted follow-up visits to evaluate progress
– Communicated information to the patient’s physician
or provider
• Linked Medication use to clinical outcome improvement
The Minnesota Experience:
637 Drug Therapy Problems Identified
Needs Additional Drug Therapy
Indication
Effectiveness
Safety
Compliance
Unnecessary Drug Therapy
34 %
6%
Ineffective Drug
12%
Dosage Too Low
20%
Adverse Drug Reaction
14%
Dosage Too High
4%
Noncompliance
10%
Source: Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211
100%
Economic Outcomes of Minnesota MTM:
Target the Disease, Then Optimize the Drug Therapy
$12,000
$11,965
$10,000
$8,000
$8,197
$6,780
$2,857
$6,000
$4,000
$2,000
$2,812
$2,499
$2,374
$2,842
1 yr pre-intervention
costs
1 yr MTM intervention
$0
Facilities $
Professional $
Precription $
Total health care cost: -31.5%
• Facility costs
-57.9%
• Professional costs
-11.1%
• Drug costs +19.7%
MTM services provided a 12:1 ROI
Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211)
Economic Outcomes of MTM Services
Summary: The Minnesota Experience
– Total annual health care cost reduced by 31.5%
post MTM from $11,965 to $8,197 (drug costs
slightly increased with 12% increase in Rx claims)
– MTM services delivered and documented by
Assurance Pharmaceutical Care System™ generated
12:1 ROI
Source: Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211
Clinical Outcomes of Minnesota MTM
Services:
• Clinical Results Improved!
– Goals of therapy improved from baseline 76% to 90% after
MTM
– 2.2 drug therapy problems per patient identified and
resolved – 78% resolved without MD
– HEDIS® Hypertension criteria achieved in 71% of MTM
patients versus 59% comparison group
– HEDIS® Cholesterol criteria achieved in 52% of MTM
patients versus 30% comparison group
Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211)
Best Practice:
1) Targeted Patients with Chronic
Conditions
2) Linked MTM to Clinical Goals in a team
approach
Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211)