Medication Therapy Management

Sample Presentation: Given to Local Employer

Background

The Need for Medication Therapy Management

Prescription drug spending in the United States was $252 billion in 2005

Medicare Part D will add $700 billion over the next 10 years

Prescription drug spending has grown by an average annual rate of 11-15% over the past 5 years

Background

The cost of drug therapy related morbidity and mortality is the 5th most costly health condition

The cost related ratio is for every $1.00 spent on medication an additional $1.30 is spent managing drug therapy problems

The estimated 2000 cost was $177 billion

Institute of Medicine July 2006 report

Several organization including CMS, NCQA, and others have called for action

Johnson JA, Bootman JL: Arch Intern Med 1995;155:1949 and

Ernst FR et al. J Am Pharm Assoc 2001;41:192

COSTS OF DRUG THERAPY PROBLEMS

Total U.S. Costs = $177 billion / year

Physician/Urgent Care Visits $ 14 billion +Added Medications $ 3 billion +Emergency Room Visits $ 6 billion +Hospital Visits $ 121 billion +Long-term Care Stays $ 33 billion

Ernest FR and Grizzle AJ. Drug-Related Morbidity and Mortality: Updating the Cost-of-Illness Model J. APhA 41: March 2001.

Business Case

WHO Definition of a Healthy Workforce

Four Key Attributes

• Healthy

• Productive

• Ready

• Resilient

Business Case

Focus of Pharmaceutical Costs

Focus Unit Pricing Utilization Therapuetic Mix

Strategy Volume

Purchasing

Financial incentives for key stakeholders

Access control

Substitution based on cost

Tactics

Pharmacy

Management

Consolidation

Restrict formularies/ contracting

Benefit design

Prior authorization

Generic substitution “step care”

Now Which Way?

Value Management

Cost Management

Cost Management

Carve out silo management

Focus on unit price

–Ties copayment to acquisition price

Limit access

Value Management

Focus on cost/benefit

Access based on evidence of value

Financing based on ROI to payer

Impact of Health on Productivity

Average Number of Unproductive Hours by Condition in a

Typical 8 Hour Work Day*

Condition Heart Disease 4.3 Respiratory Infection 4.1 Diabetes 4.0 Migraine 3.4 High Blood Pressure 3.4 Arthritis 3.2 Allergies 2.8 High Stress 2.3 Anxiety 2.2 Depression 2.2

On days when affected by the condition/Sample size = 563 Source: Medstat

Value Proposition for a Medication Therapy Management as a Benefit

Proper use of medications can lead to improved health, enhanced quality of life, and increased productivity

Overuse, under-use, and misuse of drugs is linked to reduced health, poor quality of life, and decreased productivity

Clinical pharmacists with advanced training can reduce drug therapy problems and improve health and economic outcomes

Patient-centered MTM services have consistently provided a $4:$1 ROI*

* Sources Wilcox S, Himmelstein D, Wolhander S: JAMA 1994;272:292-296 Col N, Finale J, Kronhom P: Arch Intern Med 1990;150:841-845

Isetts B, Brown L, Schondelmeyer S, Lenarz L: Arch Intern Med 2003;163:1813-1820 Zarowitz B, Stebelsky L, Muma B, Romain T: Pharmacotherapy 2005;25(11):1636-1645

Garrett D, Bluml B: J Am Pharm Assoc 2005;45:130-137 Cranor C, Christensen D: J Am Pharm Assoc 2003;43:160-172

Malone DC et al. Pharmacotherapy 2000;20:1149

Objectives

Transition the perspective of pharmacy benefit to: Enhance employee satisfaction Improve employee performance Improve economic outcomes Change the pharmacy care model to one of

action and prevention not reaction Improve targeting of drug therapy problems Improve health status Establish multi-risk focused interventions for

drug therapy management Develop a framework that is employee-centric Integrate MTM into the mainstream of corporate

health care

MTM Process of Care Overview

Patient-centered

Consistent and systematic processes that:

– Assess all of the patient’s drug-related needs

– Identifies drug therapy problems

– Establishes therapeutic goals

– Designs a medication therapy care plan

– Conducts follow-up visits to evaluate progress

– Communicates information to the patient’s physician or nurse provider in a collaborative practice

Goals

Individualized Establish desired goals of therapy for each

drug and measurement parameters Mutual negotiation with the patient and

health care providers when appropriate Goals are realistic based on patient’s ability Establish timelines Optimize the patients medication therapy

experience Several recommendations of the Institute of Medicine

Standardized Assessment

Assessment parameters Information about particular drug therapies

Information about non-drug therapies

Changes in drug regimens

Instructions for drug administration

Medications and products the patient requires

Assistance with drug administration devices

Information from other healthcare agencies

Referrals to other practitioners

Categories of Drug Therapy Problems

Every drug the patient receives undergoes the following evaluation:

Assessment of proper indication

–Is the drug being used unnecessary –Is additional drug therapy needed

Effectiveness of treatment –The current drug therapy is

ineffective –The dose is too low to produce the

desired response

Categories of Drug Therapy Problems

Safety –Is there an adverse drug reaction

present –Is the current drug dosage too high

Convenience –Is the patient adherent to the

therapy –Are there barriers to the patient’s

ability to comply with therapy e.g. physical, financial

Drug Therapy Problems Identified (n=5,136 patients)

Number of Drug

Therapy Problems

% of Drug Therapy Problems

Indication Unnecessary Drug Therapy

Needs Additional Drug Therapy

688

3,246

6%

28%

Effectiveness Ineffectve Drug

Dosage too Low

882

2,328

8%

20%

Safety Adverse Drug Reaction

Dosage too High

1,704

602

14%

5%

Compliance Noncompliance 2,276 19%

TOTAL: 11,726 100% Data from Medication Management Services, Inc.

Experience

The Service Value Proposition

High satisfaction with this care model

95% physician acceptance of care recommendations by pharmacists

Data documented a 50% improvement in patients meeting their therapeutic goals

Positive impact on health system utilization and employee productivity including:

– Reduction in hospitalization / clinic / ER visits

– Identification and resolution of drug therapy problems

– Employee days saved

Example Practice Profile for a Medication Therapy Management Service

Demographic Summary

700 Active Patients

1500 Documented Visits

60% female and 40% males

Average age = 62 years old

Average number of medical conditions = 6

Average number of medications = 10

The Most Frequent Indications for Drug Therapy in Practice

1. Hypertension

2. Hyperlipidemia

3. Peptic Ulcer Disease

4. Allergic Rhinitis

5. Diabetes

6. Osteoporosis

7. Pain-general

8. Arthritis Pain

9. Prevention MI/Stroke

10. Hypothyroidism

11. Depression

12. Insomnia

These 12 conditions represent 52% of all indications for drug therapy

Sources of Medications

In addition to their prescription medications:

502 patients (72%) were taking 2010

different OTC medications 19 patients were taking 36 different

medications they received from friends or family members

21 patients were also using 43 different sample products to manage their medical conditions

Practice Analysis (n = 700 patients)

724 drug therapy problems were identified and resolved

385 patients (55%) had > 1 drug therapy problem

98 patients (14%) had > 3 drug therapy problems

Drug Therapy Problems Identified

% of Drug Therapy Problems

Indication Unnecessary Drug Therapy

Need Additional Drug Therapy

12%

26%

Effectiveness Ineffective Drug

Dosage too Low

9%

17%

Safety Adverse Drug Reaction

Dosage too High

19%

10%

Compliance Noncompliance 7%

Total Number of Drug Therapy Problems: 724

Ten Most Common Drug Therapy Problems and Associated Medical Conditions

Dosage too low Hypertension Needs additional drug therapy Allergic rhinitis Adverse drug reaction Hypertension Dosage too low Arthritis Pain Adverse drug reaction Arthritis Pain Adverse drug reaction Hyperlipidemia Needed additional drug therapy Depression Dosage too low Allergic rhinitis Needed additional drug therapy Angina pectoris Needed additional drug therapy Esophagitis

Program Outline

Eligibility of 4 or more drugs or 2 or more chronic illness

6 – 8 service sites

Active employees and retirees

Program would be voluntary and participants would consent to the program

Participants would not be assessed a copayment for pharmacist visits

Incentives to participate

– Reduction in medication copayments

– other

Program Outline

Employees and retirees could self-refer to the program or be referred by their physician or other provider

Concerted internal effort to educate and recruit active employees and retirees into the program

Program Outline

Targeting effort to the following groups as much as possible

– Retirees and active employees with complex drug therapies

– 4 or more concurrent drugs

– Multiple physicians and pharmacies

– Recent hospitalization

– More than two chronic illnesses e.g. diabetes mellitus, COPD

– High risk drug therapies such as cardiovascular drugs, diuretics, non-opioid analgesics, anticoagulants, and antidiabetic agents

Additional Support Service

Integration with wellness screening

– Cholesterol testing

– Diabetes mellitus testing

– Spirometry

Special group classes

– Diabetes education

– Proper inhaler devise use techniques

– Smoking cessation

MTM Program Metrics

Employee satisfaction

Clinical outcomes – Reduction in drug therapy problems – Improvement in clinical measures

Return on investment and value analysis

– Direct health care costs – Absenteeism – Presenteeism*

*The World Health Organization Health and Work Performance Questionnaire (HPQ) will be used to assess employee at work performance

Financial Support

Plan would cover MTM service for active employees and retirees for.

Promotional program

Retiree Cost – Benefit Analysis

Estimated utilizers based on Rx utilization would be 64.1% of 1309 members or 839 and 70% enrollment (587 members)

Average visits of 4 - 6 per year at a cost of $65 per visit or $325 per year per enrollee

Estimated clinical visit costs $190,000

Copayment reductions based on 60% generic use and copayments of $5 and $20 and average of 2.5 Rxs/month/retiree

– 17,610 Rxs at ave copay of $10 would be $176,100

Total cost $366,000

Retiree Cost – Benefit Analysis

Blue Cross Blue Shield Cohort Study--ROI 5 to 1.(Compared total health care costs of APCS managed population versus unmanaged.)

Caremark results of 4:1 ROI

Asheville North Carolina ROI of 4:1

Minnesota Medicaid results to date = $155 per visit and cost of $72.50

Estimated ROI for City program would be estimated at $755 per enrollee or an ROI of about 2.38:1

Organizations Who Have Embarked on Similar Programs

Minnesota Medicaid program

City of Asheville NC

VF Corporation - Greensboro, NC

Mohawk Industries – Dublin, GA

Manitowoc Health Care Cooperative – WI

The Ohio State University

The Kroger Company – Columbus, OH

The University of Kentucky

West Virginia State Employees

Blue Ridge Paper

City of Chicago