The Value of Medication Therapy Management Services

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:

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

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:

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:

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:

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.”

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.”

 Evaluate appropriateness, effectiveness, safety, and compliance with medications  Identify drug therapy problems Experienced Decision Making Practitioner Medication Experience Patient Therapeutic Relationship  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 ASSESSMENT 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 Medication Therapy Management Process

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

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

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 (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.

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:

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:

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:

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):

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):

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):

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

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 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): Isetts, et al., J Am Pharm Assoc. 2008;48(2): Bunting BA, Cranor CW. JAPhA. 2006; 46: Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:

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 –Disease state quality goals

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

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 – is to be used for a first-encounter service (up to 15 minutes) – is to be used for a follow-up encounter with an established patient (up to 15 minutes) – may be used with either or 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 American Medical Association: Chicago, IL.

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 American Medical Association: Chicago, IL. CPT Code Definition of MTMS

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): Isetts, et al., J Am Pharm Assoc. 2008;48(2): Bunting BA, Cranor CW. JAPhA. 2006; 46: Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:

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 decreased 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