1. Place Logo Here The Value of Medication Therapy Management Services

2. Place Logo Here ORIGINS AND DEVELOPMENT OF MTMS

3. Place Logo Here Milestones in the Evolution of the Pharmacist as a Clinician 1949 – The Elliott Commission recommends that pharmaceutical education move toward a doctor of pharmacy degree. 1973 – APhA endorses the concept of “clinical pharmacy” in practice. 1975 – The Millis Commission recommends more clinical education and courses in social and behavioral sciences to recognize pharmacists’ growing patient care roles.

4. Place Logo Here Milestones in the Evolution of the Pharmacist as a Clinician 1990 – Hepler and Strand propose the concept of ‘Pharmaceutical Care’ “Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life” 1990 – OBRA ’90 requires pharmacists to perform DUR and to offer to counsel Medicaid patients; most states eventually extend these requirements to all patients.

5. Place Logo Here Milestones in the Evolution of the Pharmacist as a Clinician 1991 – APhA proposes Pharmacy’s mission: “The mission of Pharmacy is to serve society as the profession responsible for the appropriate use of medications, devices and services to achieve optimal therapeutic outcomes”

6. Place Logo Here Milestones in the Evolution of the Pharmacist as a Clinician 1993 – NCPA proposes the concept of ‘Pharmacist Care’ “Pharmacist Care is a comprehensive approach to pharmacist-directed patient care management through which pharmacists provide an expanded level of patient care that focuses on disease prevention and wellness programs and includes monitoring, evaluating, counseling, intervening and directing medication-related therapies to enhance patient care and improve health outcomes”

7. Place Logo Here Milestones in the Evolution of the Pharmacist as a Clinician 2003 – Medicare Modernization Act (MMA) is passed; creates an outpatient prescription drug benefit for Medicare recipients. The MMA recognizes patients’ need for medication therapy management services (MTMS) and the role of pharmacists as providers of MTMS.

8. Place Logo Here …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

9. Place Logo Here 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

10. Place Logo Here Pharmacists’ Evolving Role From Dispensing Services… …to a clinical service provider

11. Place Logo Here 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

12. Place Logo Here 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

13. Place Logo Here 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

14. Place Logo Here 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.

15. Place Logo Here 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. CPT Code Definition of MTMS

16. Place Logo Here ACTIVITIES INCLUDED IN MTMS

17. Place Logo Here 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

18. Place Logo Here 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

19. Place Logo Here 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

20. Place Logo Here 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

21. Place Logo Here 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) APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

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

23. Place Logo Here 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.”

24. Place Logo Here PHARMACISTS ROLE IN THE HEALTH CARE TEAM

25. Place Logo Here they are integral members of the health care team! Pharmacists do not work in silos….

26. Place Logo Here Physicians Value Pharmacists “Working with the pharmacist has helped me to focus on the things that only I can do as a physician.”

27. Place Logo Here  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

28. Place Logo Here Pharmacist/Prescriber Relationship

29. Place Logo Here 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

30. Place Logo Here Medication 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

31. Place Logo Here VALUE OF MTMS

32. Place Logo Here APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

33. Place Logo Here 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

34. Place Logo Here EVIDENCE OF THE VALUE OF MTMS

35. Place Logo Here Studies Illustrating Value of MTMS Asheville Project: Diabetes Asheville Project: Asthma Diabetes Ten City Challenge Minnesota Experience Project

36. Place Logo Here 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.

37. Place Logo Here 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.

38. Place Logo Here Clinical Outcomes of MTMS The Asheville Project - Diabetes Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173–84. APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

39. Place Logo Here Asheville Total Health Care Costs 1 Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84. APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

40. Place Logo Here Average Annual Diabetic Sick-Leave Usage (City of Asheville) APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

41. Place Logo Here 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 Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84.

42. Place Logo Here 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.

43. Place Logo Here 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.

44. Place Logo Here Economic Outcomes of MTMS The Asheville Project - Asthma Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

45. Place Logo Here Clinical Outcomes of MTMS The Asheville Project - Asthma Improved Asthma control sustained over 5 years 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

46. Place Logo Here 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) Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

47. Place Logo Here 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.

48. Place Logo Here 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 self- management goals –Recommended changes in therapy when appropriate Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

49. Place Logo Here 10 City Challenge Economic Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

50. Place Logo Here 10 City Challenge Clinical Outcomes after Year 1 HEDIS process measures for patients with diabetes Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

51. Place Logo Here 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 HEDIS process measurement goals for patients with diabetes Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

52. Place Logo Here 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

53. Place Logo Here 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

54. Place Logo Here Economic Outcomes from the Minnesota Experience Project

55. Place Logo Here Clinical Outcomes from the Minnesota Experience Project HTN n = 254; p=0.03 Dyslipidemia n = 254; P=0.001 Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

56. Place Logo Here 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

57. Place Logo Here 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

58. Place Logo Here 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 improved 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.

59. Place Logo Here ELEMENTS OF MTMS BENEFIT DESIGN

60. Place Logo Here Elements of MTMS Plan Design Eligibility Reimbursement structure Member engagement strategy –Incentives

61. Place Logo Here Eligibility Eligibility for a MTMS benefit can be based on: –Number of medications –Specific chronic conditions –Total amount of prescription expenditures

62. Place Logo Here 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

63. Place Logo Here 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

64. Place Logo Here Example: MN Medicaid Payment Structure Level Assessment of Drug-related needs Identification of Drug Therapy Problems Complexity-of-Care Planning & FU Evaluation Approx. Face-to- Face Time Bill CPT Code Units 1 Problem-focused-at least 1 medication Problem-focused 0 drug therapy problems Straightforward 1 medical condition 15 min. 99605 or 99606 1 unit 2 Expanded Problem- at least 2 medications Expanded Problem at least 1 drug therapy problem Straightforward 1 medical condition 16-30 min. 99605 or 99606 and 1 unit 996071 unit 3 Detailed- at least 3-5 medications Detailed at least 2 drug therapy problems Low complexity at least 2 medical conditions 31-45 min. 99605 or 99606 and 1 unit 996072 units 4 Expanded Detailed- at least 6-8 medications Expanded Detailed at least 3 drug therapy problems Moderate Complexity at least 3 medical conditions 46-60 min. 99605 or 99606 and 1 unit 996073 units 5 Comprehensive- >= 9 medications Comprehensive at least >4 drug therapy problems High Complexity at least >= 4 medical conditions 60 + min. 99605 or 99606 and 1 unit; 996074 units

65. Place Logo Here Example: Outcomes Pharmaceutical Health Care Pharmacist ServiceCPT Codes Comprehensive Medication Review99605 + 99607 Physician Consultation99606 + 99607 Patient Compliance Consultation99606 + 99607 Patient Education/Monitoring99606

66. Place Logo Here 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

67. Place Logo Here 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

68. Place Logo Here 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

69. Place Logo Here 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