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The Value of The Value of Medication Therapy Medication Therapy

Management ServicesManagement Services

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ORIGINS AND DEVELOPMENT ORIGINS AND DEVELOPMENT

OF MTMSOF MTMS

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Milestones in the Evolution of the Pharmacist as a

Clinician

1949 – The Elliott Commission recommends that pharmaceutical education move toward a doctor of pharmacy degree.

1973 – APhA endorses the concept of “clinical pharmacy” in practice.

1975 – The Millis Commission recommends more clinical education and courses in social and behavioral sciences to recognize pharmacists’ growing patient care roles.

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Clinician

1990 – Hepler and Strand propose the concept of ‘Pharmaceutical Care’

“Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life”

1990 – OBRA ’90 requires pharmacists to perform DUR and to offer to counsel Medicaid patients; most states eventually extend these requirements to all patients.

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Clinician

1991 – APhA proposes Pharmacy’s mission:

“The mission of Pharmacy is to serve society as the profession responsible for the appropriate use of medications, devices and services to achieve optimal therapeutic outcomes”

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Clinician

1993 – NCPA proposes the concept of ‘Pharmacist Care’

“Pharmacist Care is a comprehensive approach to pharmacist-directed patient care management through which pharmacists provide an expanded level of patient care that focuses on disease prevention and wellness programs and includes monitoring, evaluating, counseling, intervening and directing medication-related therapies to enhance patient care and improve health outcomes”

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Clinician

2003 – Medicare Modernization Act (MMA) is passed; creates an outpatient prescription drug benefit for Medicare recipients. The MMA recognizes patients’ need for medication therapy management services (MTMS) and the role of pharmacists as providers of MTMS.

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…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

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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

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Pharmacists’ Evolving Role

From Dispensing Services… …to a clinical

service provider

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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

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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

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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

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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.

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• 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

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ACTIVITIES INCLUDED IN ACTIVITIES INCLUDED IN MTMSMTMS

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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


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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


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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


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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


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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 theirmedications and relatedconditions:Medication-Related Action Plan(MAP)


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Value of a Personal Medication Record

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

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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.”

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PHARMACISTS ROLE IN THE PHARMACISTS ROLE IN THE

HEALTH CARE TEAMHEALTH CARE TEAM

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they are integral members of the

health care team!

Pharmacists do not work in

silos….

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Physicians Value Pharmacists

“Working with the pharmacist has helped me to focus on the things that only I can do as a physician.”

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Evaluate appropriateness, effectiveness, safety, and compliance with medications

Identify drug therapy problems

Exp

erienced

Decisio

n M

aking

PractitionerM

edic

atio

n E

xper

ien

ce 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

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Pharmacist/Prescriber Relationship

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Pharmacist’s Communication

with other Health Providers

• 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

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Medication Recommendations

• 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

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VALUE OF VALUE OF MTMSMTMS

Place Logo Here APhA. Pharmacists Improving Care and Reducing Costs for

Your Plan Participants. Available at: www.pharmacist.com

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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

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EVIDENCE OF THE VALUE OF EVIDENCE OF THE VALUE OF

MTMSMTMS

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Studies Illustrating Value of MTMS

• Asheville Project: Diabetes

• Asheville Project: Asthma

• Diabetes Ten City Challenge

• Minnesota Experience Project

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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.

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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


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Clinical Outcomes of MTMSThe Asheville Project - Diabetes



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Asheville Total Health Care Costs1

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Baseline 1 2 3 4 5

Follow-up Year

Mean

Co

st

/ P

ati

en

t /

Year

Medical $ Diabetes Rx Other Rx

Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84.


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Average Annual Diabetic Sick-Leave Usage (City of Asheville)

12.6

6

8.46

5.68 5.81 5.67 6.01

0

2

4

6

8

10

12

14

Basel

ine

Year

1

Year

2

Year

3

Year

4

Year

5

Year

6


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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


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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 programBunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

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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.

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Economic Outcomes of MTMSThe Asheville Project - Asthma


0

2

4

6

8

10

12

14

Percentage

BY3 BY2 BY1 Y1 Y2 Y3 Y4 Y5

% Patients withER/ Hospital Events

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Clinical Outcomes of MTMSThe Asheville Project - Asthma

Improved Asthma control

sustained over 5 years



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Key Findings: Asheville Asthma


– Decreased percentage of asthma patients requiring emergency and hospital care


– Improved asthma control sustained over 5 years

(as evidenced by FEV1 measurements)


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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.

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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


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10 City Challenge Economic Outcomes after Year 1

0123456789

Cost in Millions

MedicalCosts

Medicationcosts

PharmacyServices

Costs

TotalHealth Care

Costs

Baseline

Year 1ProjectedYear 1Actual


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10 City Challenge Clinical Outcomes after Year 1

0102030405060708090

100

Percentage of Participants

A1C testing A1C <9% A1C <7% Lipid testing LDL <100mg/dL

BP <130/80 Eye exams Flu vaccine Foot exams

DTCC Baseline

DTCC Year 1

HEDIS process measures for patients with diabetes


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Key Findings: 10 City Challenge


– Total health care costs were less than predicted

– Prescription costs increased, but overall health care

costs decreased


– Increased percentage of patients meeting HEDIS process measurement goals for patients with diabetes


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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

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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


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Economic Outcomes from the Minnesota Experience

Project

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

Facilities (- 57.9%)

Professional (- 11.1%)

Prescriptions (+ 19.5%)

Total Cost (- 31.5%)

1 YearbeforeMTM

1 YearafterMTM

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Clinical Outcomes from the Minnesota Experience

Project

HTN n = 254;p=0.03

Dyslipidemia n = 254;P=0.001


0

10

20

30

40

50

60

70

80

Hypertension Dyslipidemia

% of patients meeting

HEDIS goals

MTM GroupNo MTM

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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 $8,197


– The MTM intervention group had a higher percentage of patients meeting HEDIS goals for hypertension and dyslipidemia

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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

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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 improved 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. 2008;48(2):203-211Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.


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ELEMENTS OF MTMS ELEMENTS OF MTMS

BENEFIT DESIGNBENEFIT DESIGN

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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

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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

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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

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Example: MN Medicaid Payment Structure

LevelAssessment of

Drug-related needs

Identification of Drug Therapy Problems

Complexity-of-Care Planning & FU

Evaluation

Approx. Face-to-

Face Time

Bill CPT Code

Units

1Problem-focused-at least 1 medication

Problem-focused 0 drug therapy problems

Straightforward 1 medical condition 15 min.

99605 or99606

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 or99606 and

1 unit

99607 1 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 or99606 and

1 unit

99607 2 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

99607 3 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;

99607 4 units

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Example: Outcomes Pharmaceutical Health Care

Pharmacist Service CPT Codes

Comprehensive Medication Review 99605 + 99607

Physician Consultation 99606 + 99607

Patient Compliance Consultation 99606 + 99607

Patient Education/Monitoring 99606

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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

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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

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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

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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

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