medication therapy management (mtm) master class · 2018. 5. 24. · member’s other primary care...

CARON WINGERCHUK, PHARM.D.

Senior Director, Pharmacy Solutions

LISA ERWIN, RPH

Senior Consultant, Pharmacy Solutions

MEDICATION THERAPY MANAGEMENT (MTM) MASTER CLASS

MTM BACKGROUND

Copyright © 2018 Gorman Health Group3

BACKGROUND

In the United States, 3.8 billion prescriptions are written annually

Approximately 1 in 5 new prescriptions are never filled

Among those filled, approximately 50% are taken incorrectly

Direct healthcare costs associated with non-adherence have grown to

approximately $100-$300 billion of U.S. healthcare dollars spent annually

https://www.cdc.gov/mmwr/volumes/66/wr/mm6645a2.htmOsterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487–97


BACKGROUND

Prescriptions drugs comprise 10.1% of healthcare expenditures.

This represents the third most costly component of the nation’s

health spending behind hospital care (32.3%) and physician and

clinical services (19.8%).

http://www.cdc.gov/nchs/fastats/health-expenditures.htm-2015 data

Cost Implications

http://www.cdc.gov/nchs/fastats/health-expenditures.htm-2015 data


MTM SERVICES: BROAD DEFINITION

MTM, in its most simplistic definition, refers to activities that aim to

optimize drug therapy in patients and prevent negative events.


These services include but are not limited to the following, according to the individual needs of the member:

• Performing or obtaining necessary assessments of the member’s health status

• Formulating a medication treatment plan

• Selecting, initiating, modifying, or administering medication therapy

• Monitoring and evaluating the member’s response to therapy, including safety and effectiveness

MTM SERVICES: BROAD DEFINITIONMTM Background


• Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events

• Documenting the care delivered and communicating essential information to the member’s other primary care providers

• Providing verbal education and training designed to enhance member understanding and appropriate use of his/her medications

• Coordinating and integrating MTM services within the broader healthcare management services being provided to the member

• Moving to achieve a model that is consistent, comprehensive, and collaborative in order to improve MTM results

MTM SERVICES: DEFINITION (CONTINUED)

MTM Background


MTM ALIGNS WITH TRIPLE AIM

Better Health for

the Population

Better Care for the

Individual

GOAL

ReducedExpenditure


ENHANCED MTM INITIATIVE

CMS’ Center for Medicare & Medicaid Innovation (CMMI) has developed the Enhanced MTM Model:

• Allows sponsors regulatory flexibility and financial resources to design MTM programs that best fit their beneficiaries’ needs

• Goal of this innovative MTM model is to align the interest of Part D sponsors and CMS

• MTM services help manage chronic disease, reduce medical errors, and improve patient adherence to therapies while reducing acute care costs and hospital readmissions

Part D’s inherent structure makes it particularly challenging to create and sustain robust MTM programs


PDP MISALIGNED INCENTIVES

Historically, Prescription Drug Plans (PDPs) have provided MTM that meets minimum standards for regulatory compliance

Comprehensive Medication Review (CMR) completion rate for PDPs is about 50% lower than MA-PDs based on 2016 Star Ratings measure

Costs for these MTM programs are included in the administrative cost of a plan’s Part D bid, not an additional benefit

• Low return on investment

• PDPs carry low beneficiary premiums

• Responsible for drug benefits

PDPs do not have access to medical claims and have a limited view of member diagnoses

Reliance upon drug therapy/claims to identify medical conditions (e.g., insulin use and diabetes)

10


MTMNeed for Standardized Documentation

↘ Historically, there has been an inability to track outcomes due to no agreed upon standard

↘ First attempt at standardization was CMR template format

↘ CMMI created opportunity to develop standardized reporting for outcomes and billing


SNOMED EVOLUTION

Required to document and report clinical information using SNOMED CT®

Need for a consistent and standardized set of definitions for MTM services to allow for comparisons in outcomes across various provider types, healthcare settings, and patient populations


SNOMED CLASSIFICATIONSThe Devil Is In The Detail


PROGRAM OPTIMIZATION – EXPANDED CRITERIA


PROGRAM OPTIMIZATION

Diabetes, chronic heart failure (CHF), and dyslipidemia remained the top targeted diseases in 2017, with chronic obstructive pulmonary disease (COPD) replacing hypertension as the 4th most targeted disease

Other beneficiary conditions that are targeted by more than 10% of the 2017 MTM programs included:

• End-Stage Renal Disease (ESRD)(16.9%)

• HIV/AIDS (13.5%)

• Hepatitis C (13.0%)

• Alzheimer’s Disease (12.3%)


Is CMS decreasing the emphasis on MTM since audits have been suspended?

• Unlikely

• Meaningful way to audit

• SNOMED potential impact

Audit findings

• Failure to properly enroll members who met the targeting criteria

• Insufficient member outreach

• Inadequate safeguards against discrimination

• Inappropriate disenrollment

• Year over year

• Opt out

• “Bad phone numbers”

• Inadequate communication between delegated PBM or MTM vendor

• Cases where the PBM could not reach members who qualified

• Oversight by the plan of the delegation of MTM

MTM AUDIT EXPERIENCEKey Takeaways


DELEGATED OVERSIGHT & MONITORING

Annually review MTM program to ensure compliance with CMS requirements, including but not limited to:

• Developed in cooperation with licensed physicians and pharmacists

• Targets enrollees with specific, multiple chronic conditions

Quarterly, review number of members enrolled in the MTM program


Quarterly, review number of members who have opted out of the MTM program and reasoning (voluntary, deceased, etc.)

• Ensure opt-out members are permanently removed from future program correspondence unless member specifically requests program information

Quarterly, review members with completed CMRs

Quarterly, review members receiving targeted monitoring

Monthly, cross-walk members in MTM program with members being case managed

Quarterly, review utilization and outcome measures reported for all MTM program enrollees

Ensure receipt of annual survey results

DELEGATED OVERSIGHT & MONITORINGMTM


PLANS USE A HYBRID MODEL TO DELIVER MTM SERVICES

In 2017, more plans moved to deliver at

least a portion of MTM services in-

house

•92.9% of programs

use outside personnel

•53.2% of programs

use internal staff

IS A “CLOSED HMO-LIKE SYSTEM” THE ONLY WAY

TO ACHIEVE HIGH CMR RATES?


WHAT IS A “HIGH PERFORMING” MTM PROGRAM?More Plans Achieved > 4 Stars in 2018

PLAN TYPES H PLAN 4/5 STAR PERFORMERS S PLAN 4/5 STAR PERFORMERS

630 total plans in Star Ratings measure universe

186 unreported (no data, too new, data errors)

Those reporting CMR completion rates include:

• 368 CCP/H Plans• 50 PDP/S Plans• 21 RCCPs/R Plans• 5 1876 Cost Plans

220 H Plans achieved 4 stars (59%) or above:

• 69 plans achieved 5 stars (>=75%)

• 151 plans achieved 4 stars (>=59% - <75%)

18 S Plans achieved 4 stars (39%) or above

• 11 plans achieved 5 stars (> 53%)

• 7 plans achieved 4 stars (>=39% - <53%)


LARGE-SCALE MTM VENDORS

SINFONÍARX PHARM MD OUTCOMES MTM MIRIXA

Affiliated with academic, credentialed Colleges of Pharmacy – The University of Arizona (U of A) and The Ohio State University (OSU).

Scalable, remote MTM pharmacist pool.

Historically, business model was based on face-to-face retail pharmacist interventions.

Platform designed to push drug therapy issues to the pharmacy and not necessarily for flexibility upon actual review with the patient.

Patient services are completed through centralized clinical providers who are located at direct SinfoníaRx locations and colleges of pharmacy.

Robust MTM scheduling capabilities to optimize pharmacist time and efficiency.

Expanded into a telehealth option for CMR completion in September of 2015 –administered by Cardinal Health.

Call center services available.

Qualified approximately 14.1% of about 5 million Medicare patients in 2017 book of business.

Can provide sophisticated clinical MTM platform, outreach, or both.

Not typically utilized as a sole MTM provider but as part of a hybrid model.Case completion rate payment model with downstream payments to pharmacists per CMR/TMR.

Announced integration of Equipp data into MirixaPro so pharmacies can track their store Star Ratings results.


PROCESS MEASURES

• Number of outbound calls

• Interventions received

• Eligibility

• Therapy issues identified

ECONOMIC MEASURES

• Change in prescription costs

• Change in medical costs

QUALITY INDICATORS

• Change in therapy

• Persistence/Adherence

• Drug-drug interactions

• Polypharmacy

• Over-/Under-utilization

WHAT OUTCOMES SHOULD PROGRAMS BE EVALUATING?

MTM Reporting


IN-HOUSE PROGRAM RECOMMENDATIONS

Utilize a standardized outbound call script that is developed by the pharmacy technician team –create consensus about what works best.

Include a member questionnaire in the initial mailing so members have a more compelling reason to enroll in MTM.

Prioritize members who completed a CMR in the past as more likely to agree to another in the current plan year.

Use a progress report to assign daily CMR targets to help close the daily/weekly/monthly goals rather than waiting for the vendor’s more open-ended processes and shifting strategies.

Update MTM vendor SOWs to require vendor CMR and clinical performance reporting in real time, consistent format, and in an integrated documentation platform.

Integrate pharmacy students/interns into CMR processes to improve efficiency at a reduced cost.


NOVEL MTM APPROACHES

EMBEDDING PHARMACISTS

ELECTRONIC DATA SHARING ACROSS PLATFORMS

MTM CONSULTS ON SPECIALTY MEDICATIONS

MTM TO SUPPORT STAR RATINGS

MTM IN COMMERCIAL AND EMPLOYER LIVES


“Whether you’d like to work with community pharmacists or embed pharmacists in your practices, the

MTM program and the identification and elimination of medication problems—keeps patients safe

while reducing costs. You can communicate the advantages of the program to your providers and

patients while incorporating appropriate MTM referrals in your care management work flow. Your

patients will benefit from the rich menu of interventions, your care managers and mid-level providers

will have a reduced burden and the cost of care for your most vulnerable patients will decrease.”

A mid-size plan made this offer to Accountable Care Organizations (ACOs) on behalf of their fully-funded and self-funded commercial

members in addition to Medicare members.


CONSIDER EMBEDDING PHARMACISTS IN MEDICAL PRACTICES

↘ If significant % of members are aligned with ACO/ Patient-Centered Medical Homes (PCMHs)

↘ Ability to address both MTM and Star Ratings Gaps

↘ Close remaining CMR and Star Ratings Gaps using retail pharmacists or value-based pharmacy arrangements


STAR RATINGS CROSSOVER METRICSIntegrating Medication Reconciliation and MTM

MTMMEDICATION

RECONCILIATION

67% of patients were taking at least one additional prescription medication that was not discovered from using the claims database alone.

http://cqm.pharmacy.ufl.edu/files/2013/03/Integrating-Medication-Reconciliation.pdf

At least one discrepancy was found in the medication list for 99% of the subjects.

Some patients were using medications provided to them as samples or from other sources such as from a family member.

67%


STAR RATINGS CROSSOVER METRICS: HOSPITAL READMISSIONS

Patients in the study were recruited from 2 local hospitals and had received a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or pneumonia.

20% of those who received usual care were readmitted to the hospital within 30 days

vs.

6.9% of those who received MTM services from a pharmacist.

Greater levels of understanding about their medications and better recognition of symptoms associated with their disease states.

http://www.pharmacytimes.com/news/pharmacist-mtm-proven-to-reduce-hospital-readmission


STAR RATINGS CROSSOVER METRICS: HEDISStatin Use in Cardiovascular Disease

SUPD

Low intensity

SUPD

SPC

Moderate intensity

SUPD

SPC

High intensity

MTM can help find the right patient for the right drug to support these overlapping measures

ADHERENCE


TRANSITIONS OF CARE

The movement of patients from one healthcare practitioner or

setting to another as their condition and care needs change

OCCURS AT MULTIPLE LEVELS

• Between settings: Hospital ↔ Sub-acute facility, Hospital ↔ Home

• Within settings: ICU ↔ Ward

ACROSS HEALTH STATES

Curative care ↔ Palliative care/Hospice


WHAT ARE TRANSITIONS OF CARE?

A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care

Based on a comprehensive care plan and availability of well-trained practitioners who have current information about the patient’s goals, preferences and clinical status

INCLUDES:

• Logistical arrangements

• Education of the patient and family caregiver

• Coordination among the health professionals involved in the transition

• Medication management

• Transition planning

• Patient and family engagement/education

• Information transfer

• Follow-up care

• Healthcare provider engagement

• Shared accountability across providers and organizations

Coleman EA, Boult C, The American Geriatrics Society Health Care Systems Committee. J Am Geriatr Soc 2003;51:556-7.


TRANSITION OF CARE MEASURES

Inclusion of Transition of Care measures are becoming more common for nationally recognized quality programs including:

NCQA’S PCMH STANDARDS & ELEMENTSCMS MEANINGFUL USE REQUIREMENTS

(CORE AND MENU)

3C: Care Management

3D: Medication Management • Performs medication reconciliation

5B: Referral Tracking and Follow-Up• Exchange key clinical information among

providers of care

5C: Coordinate with Facilities and Care Transitions• Provide summary care record for each

transition of care or referral


2019 CALL LETTER

Support Innovative Approaches to Improving Quality, Accessibility, and Affordability

MLR is a formula used to calculate how much insurance companies must spend out of each premium dollar.

MLR provides a financial incentive for health insurers to reduce administrative costs and spend more on healthcare quality activities.

MTM being considered a healthcare quality-improving activity makes plans more likely to invest in and offer MTM.

2019 Call Letter – MTM should be incorporated as a component of MLR rather than an administrative function.

• Would further encourage and incentivize providers to strengthen their MTM programs.


CMS provided summary document for the evidence supporting MTM program value

ROI published ranges ~ $1.00 to $12.00 per dollar spent

Many variables based on patient population complexity and length of study

MTMReturn on Investment (ROI)

https://innovation.cms.gov/Files/x/mtm-evidencebase.pdf


MLR

Enables Expansion of MTM Programs

Better Integration with Case Management

Develop Adherence Monitoring


MTM INNOVATION OPPORTUNITIES

HEALTHCARE TODAY

Uncoordinated

Unsupportive

Unsustainable HEALTHCARE TOMORROW

Accessible

Affordable Quality-driven


Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across eight verticals

CLINICALPairing clinical teams with innovation to provide patient-centered care

PROVIDER STRATEGIESSupporting network design and medical cost control implementation

OPERATIONSBringing excellence to every aspect of your implementation — from enrollment to claims payment

COMPLIANCEOffering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACYLeading experts in Part D, Pharmacy Benefit Manager, formulary, and pharmacy programs

HEALTHCARE ANALYTICS &

RISK ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment programs for medical trend management and quality improvement

SALES, MARKETING & STRATEGYDriving profitable growth and member retention through strategic marketing, sales, and product development

BROAD SERVICES

STAR RATINGS & QUALITY INNOVATIONSStrategic innovations to drive quality and improve

performance


Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance

Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic,

operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric

focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent

workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist

government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™

(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and

streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses

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T

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CONTACT

LISA ERWIN

Senior Consultant, Pharmacy Solutions

248.410.3309

[email protected]

CARON WINGERCHUK

Senior Director, Pharmacy Solutions

480.492.3852

[email protected]

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medication therapy management (mtm) master class · 2018. 5. 24. · member’s other primary care...

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