1. Presenter Name The Opportunity for Comprehensive Medication Management

2. 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

3. 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?

4. The Facts Four out of Five patients leave with at least one prescription 1 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 condition 2 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)

5. But what happens to those prescriptions? 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. http://www.bcg.com/publications/files/TheH iddenEpidemic_Rpt_HCDec03.pdf HealthCare Landscape Non-Compliant Behaviors

6. Why Didn’t They Take Their Medication? 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.http://www.bcg.com/publications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf 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

7. 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.

8. 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

9. 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

10. 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

11. ASSESSMENT Reveal the patient’s medication experience Identify drug therapy problems in appropriateness of, effectiveness of, safety of, and compliance with medications CARE PLAN Establish personalized goals of therapy Resolve drug therapy problems Personalize Interventions FOLLOW-UP Effectiveness and Safety Determine Actual Patient Outcomes Comprehensive Medication Management in the PCMH Core Principles of the Patient Centered Medical Home Elements of Comprehensive Medication Management

12. Optimal therapeutic recommendations are based on the experience/needs of the patient Patient Comprehensive Medication Management in the PCMH Clinical Pharmacist/ Pharmacotherapy Manager Physicians/ Providers - PCMH Patient understands his/her medications and participates in a care plan to improve health Clinical goals of therapy are determined and medication recommendations are considered Gaps in clinical goals are determined, drug therapy problems identified, and therapeutic recommendations made Appropriate, Effective, Safe and Adherent Medication Use!

13. 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

14. 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

15. 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

16. 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.http://www.diabetestencitychallenge.com/http://www.diabetestencitychallenge.com/ 2.Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: Final economic and clinical results. JAmPharmAssoc 2009, 49:383-91.

17. 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.

18. 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.

19. 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: 1996- 2000. Pharmacotherapy. 2003 Jan, 23(1):113-32.

20. 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.

21. 21 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

22. “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 22 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 http://www.nap.edu/catalog/12014.html

23. 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: erogers@pcpcc.net, (202)724-3331 Visit our website – http://www.pcpcc.net

24. Case Studies 24

25. 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

26. 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

27. Category of ServiceEstimated Savings from Benchmark Inpatient$142,085,680 Outpatient$51,865,028 Emergency Room$25,944,553 Primary Care, Specialist$45,498,709 Pharmacy$(15,526,996) Other$(5,065,238) Totals$244,801,735 North Carolina Medicaid State Fiscal Year 2004 Savings

28. 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

29. 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)

30. 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

31. The Minnesota Experience: 637 Drug Therapy Problems Identified Needs Additional Drug Therapy 34 % Unnecessary Drug Therapy 6% Ineffective Drug 12% Dosage Too Low 20% Adverse Drug Reaction 14% Dosage Too High 4% Noncompliance 10% 100% Indication Effectiveness Safety Compliance Source: Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211

32. $11,965 $8,197 Economic Outcomes of Minnesota MTM: Target the Disease, Then Optimize the Drug Therapy Isetts, et al. J Am Pharm Assoc. 2008;48(2):203-211) 31.5% 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

33. –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 Economic Outcomes of MTM Services Summary: The Minnesota Experience

34. 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)

35. Best Practice: 1) Targeted Patients with Chronic Conditions 2) Linked MTM to Clinical Goals in a team approach