1. The Value of Medication Therapy Management Services

2. ORIGINS AND DEVELOPMENT OF MTMS

3. 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

4. …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

5. 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 American Pharmacists Association

6. Pharmacists’ Evolving Role From Dispensing Services… …to a clinical service provider

7. 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

8. 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

9. 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

10. 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. Beebe M, Dalton JA, Espronceda M, et. al. Current Procedural Terminology 2009. American Medical Association: Chicago, IL.

11. 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

12. ACTIVITIES INCLUDED IN MTMS

13. 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 American Pharmacists Association

14. 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 American Pharmacists Association

15. 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 American Pharmacists Association

16. 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 American Pharmacists Association

17. 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) American Pharmacists Association

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

19. 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.”

20. PHARMACISTS ROLE IN THE HEALTH CARE TEAM

21. they are integral members of the health care team! MTM Pharmacists do not work in silos….

22. 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.”

23.  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

24. MTM Pharmacist/Prescriber Relationship

25. 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

26. Medications Recommendations MTM 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

27. VALUE OF MTMS

28. American Pharmacists Association

29. 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

30. EVIDENCE OF THE VALUE OF MTMS

31. Studies Illustrating Value of MTMS Asheville Project: Diabetes Asheville Project: Asthma Diabetes Ten City Challenge Minnesota Experience Project

32. 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.

33. 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.

34. Clinical Outcomes of MTMS The Asheville Project - Diabetes 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. American Pharmacists Association

35. Asheville Total Health Care Costs 1 American Pharmacists Association 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.

36. Average Annual Diabetic Sick-Leave Usage (City of Asheville) American Pharmacists Association

37. 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

38. 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.

39. 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.

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

41. Clinical Outcomes of MTMS The Asheville Project - Asthma Improved Asthma control sustained over 5 years Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147. American Pharmacists Association

42. 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)

43. 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; 49e52-e60.

44. 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; 49e52-e60.

45. 10 City Challenge Economic Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49e52-e60.

46. 10 City Challenge Clinical Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49e52-e60. HEDIS process measures for patients with diabetes

47. 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

48. 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

49. 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

50. Economic Outcomes from the Minnesota Experience Project

51. 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

52. 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

53. 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

54. 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.

55. ELEMENTS OF MTMS BENEFIT DESIGN

56. Elements of MTMS Plan Design Eligibility Reimbursement structure Member engagement strategy –Incentives

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

58. 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

59. 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

60. 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

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

62. 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

63. 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

64. 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

65. 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