The Value of Medication Therapy Management Services

1
The Value of Medication Therapy Management
Services
2
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
3
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 patients other health care
  providers
• .

Bluml BM. Definition of medication therapy
management development of professionwide
consensus. J Am Pharm Assoc. 20054556672
4
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
www.pharmacist.com
5
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
www.pharmacist.com
6
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
7
Value of a Personal Medication Record

• The medication record helps give the doctors a
  better picture of whats going on with me.

8
Value of MTMS
Having the help of a person who specializes in
medications, which impacts me on a daily
basisputting drugs in my body.
9
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.

10
Medication Therapy Management Process
ASSESSMENT
? Evaluate appropriateness, effectiveness,
safety, and compliance with medications ?
Identify drug therapy problems

Practitioner
Patient

CARE PLAN
Experienced Decision Making
Medication Experience
? Resolve drug therapy problems ? Establish goals
of therapy ? Interventions
? Philosophy of Practice ? Social Obligation ?
Responsibility to identify, resolve, and
prevent drug therapy problems ?
Patient-centered approach ? Caring
? Todays wants and needs ? Responsibility to
participate in information sharing and
decision making
FOLLOW-UP
? Evaluate progress in meeting goals of therapy ?
Record actual patient outcomes ? Reassess new
problems
Therapeutic Relationship
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MTM Pharmacist/Prescriber Relationship
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Pharmacists Communication with Other Health
Providers

• MTM Pharmacists will communicate regularly with
  patients primary care provider, and other health
  care team members as appropriate
• Describe assessment
• Describe and rationalize recommendations for
  medication changes
• Recommendations for follow-up

13
American Pharmacists Association
14
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
•  

15
Studies Illustrating Value of MTMS

• Asheville Project Diabetes
• Asheville Project Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project

16
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. Josephs 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. 20034317384.
17
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, plt0.05) and
  LDL (118mg/dl baseline vs. 98mg/dl after 14
  months, plt0.05)
• Humanistic benefit
• Decreased sick leave increased worker
  productivity

Cranor CW, Bunting BA, Christensen DB. J Am Pharm
Assoc. 200343173-84.
18
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. Josephs 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 46133-147.
19
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 46133-147.
20
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.
21
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) 383-391.
22
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 121

Isetts, et al., J Am Pharm Assoc.
200848(2)203-211
23
Key Findings Minnesota Experience Project

• Economic benefit
• A 121 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

24
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

25
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) 383-391. Isetts, et al., J Am Pharm
Assoc. 200848(2)203-211 Bunting BA, Cranor CW.
JAPhA. 2006 46133-147. Cranor CW, Bunting BA,
Christensen DB. J Am Pharm Assoc. 200343173-84.
26
Elements of MTMS Plan Design

• Eligibility
• Reimbursement structure
• Member engagement strategy
• Incentives

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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

28
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

29
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.
30
CPT Code Definition of MTMS

• 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.
31
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) 383-391. Isetts, et al., J Am Pharm
Assoc. 200848(2)203-211 Bunting BA, Cranor CW.
JAPhA. 2006 46133-147. Cranor CW, Bunting BA,
Christensen DB. J Am Pharm Assoc. 200343173-84.
32
Whats 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

33
Whats 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

34
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