Rex W. Force, Pharm.D., BCPS, FCCP Associate Dean for Clinical Research ISU Division of Health Sciences Characteristics of High Performing MTM Programs

I have no relevant financial relationships or commercial interests to disclose in conjunction with this presentation Disclosure

  Describe the components of medication therapy management (MTM) programs   Discuss the needs of MTM programs and outcomes that have been documented for MTM delivery   Outline processes necessary for establishing MTM services   Identify performance metrics and quality outcomes for MTM programs Objectives

Which of the following is a goal of MTM? A. Improve med adherence and reduce adverse events B. Improve pharmacist reimbursement C. Increase Part D plan ratings on the CMS website D. All of the above are goals of MTM

 MTM is a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence.  Therefore, the programs include high-touch interventions to engage the beneficiary and their prescribers.  Required of Medicare Part D providers  Is an opt-out program for beneficiaries What is MTM?

 Is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries are appropriately used to optimize therapeutic outcomes through improved medication use;  Is designed to reduce the risk of adverse events, including adverse drug interactions;  May be furnished by a pharmacist or other qualified provider What is MTM?

Why is MTM needed? N Engl J Med. 2003;348:

 At minimum 2 or 3 chronic conditions  May target disease states, but if they do must include at least 5 of the following:  Alzheimer’s Disease;  Chronic Heart Failure (CHF);  Diabetes;  Dyslipidemia;  End-Stage Renal Disease (ESRD);  Hypertension;  Respiratory Disease (such as Asthma, COPD);  Bone Disease-Arthritis (such as Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis);  Mental Health (such as Depression, Schizophrenia, Bipolar Disorder, etc.).  Maximum threshold of 8 chronic medications  Likely to incur drug costs of $3,017 in 2014 MTM Inclusion

Medication therapy review might consist of: A. Gathering medication history B. Assessing cultural or social issues that affect med use C. Developing a plan for resolving drug-related problems D. Educating the patient on appropriate med use and monitoring E. All of the above

 Interventions for both beneficiaries and prescribers.  An annual comprehensive medication review (CMR  The beneficiary's CMR must include an interactive, person-to- person, or telehealth consultation performed by a pharmacist or other qualified provider; and may result in a recommended medication action plan.  If a beneficiary is offered the annual CMR and is unable to accept the offer to participate, the pharmacist or other qualified provider may perform the CMR with the beneficiary's prescriber, caregiver, or other authorized individual.  Quarterly targeted medication reviews (TMRs) with follow-up interventions when necessary. MTM Services

 Medication therapy review (MTR)  Personal medication record (PMR)  Medication-related action plan (MAP)  Intervention and/or referral  Documentation and follow-up MTM Service Model

 Sometimes called CMR, Comprehensive Med Review  Collection of patient-specific data  Assessing therapy to identify drug-related problems  Prioritization  Plan for resolution Medication Therapy Review

 Comprehensive record of patient’s:  Medications – dose, indication, instructions, start/stop dates, prescriber, etc.  OTCs  Herbals  Vitamins, minerals, and others  Should include provider info, allergies, pharmacy, patient info, etc.  Should help engage med self-management  Carry with patient at all times  Date last updated Personal Medication Record

 Patient-centered document with list of actions related to self-management  Goal is to engage patient and encourage participation in therapy:  Checking med use and adherence, blood sugars, weights, blood pressure, dietary logs, functional status, etc. Medication-related Action Plan

 Address identified drug-related problems  Intervention and/or Referral  Collaborate with other members of the health care team  Documentation  Enhance continuity  Needed for billing  Protect against liability  Assists with documenting outcomes  Billing Next Steps

JAPhA 2008;48:341-53

Establishing MTM

 Billing  NPI numbers  CPT codes  Requirements  Business development tools  Business model  Measuring success  Marketing and promotion Establishing MTM

Getting Plugged Into MTM  Some companies act as go-between for pharmacists and Part D providers  Outcomes MTM  Mirixa  Contracting directly with Part D providers  Commercial insurance  Self-insured companies  Direct-to-patient marketing

 MTM program from  6 clinics in Minnesota with MTM and 9 clinics without  Measured: resolution of drug therapy problems, attainment of HEDIS measures for hypertension and dyslipidemia Outcomes of MTM JAPhA 2008;48(2);

 637 drug-related problems in 285 patients addressed (2.2/patient)  33.9% needed add’l drug therapy  19.9% needed increased drug dose  14.1% had adverse effect  9.6% non-adherent with regimen  HEDIS measures for:  BP improved, 71% v. 59% (p=0.03)  Lipids improved, 52% v. 30% (P=0.001)  31% reduction in total health care costs for MTM patients  ROI $12.15 per $1 spent on MTM Outcomes of MTM JAPhA 2008;48(2);

 Patient satisfaction with telephonic MTM  5-point Likert scale (5=strongly agree)  60 subjects received MTM and then surveys  80% survey response  Overall mean satisfaction score was 4.0 (+/-0.6)  Happy with ability to contact pharmacist, get questions answered, content with MTM over the phone (mean=4.3)  Less happy with referral for preventive services and other health care providers (mean=3.6) Outcomes of MTM Res Soc Admin Phar 2010;6:143-54

Outcomes of MTM  Impact of MTM on mortality, hospitalization, ED use, daily Rx costs  Matched cohort study  Received MTM between  34,532 with MTM matched to 138,128 without  Controlled for several variables  Significant 14% reduction in mortality in MTM group  3% reduction in hospitalizations although ED visits increased in the MTM group  No difference in daily medication costs AJMC 2014;20(2):e43-e51.

 # Rx per day  Generic conversions  Labor costs/Rx  Rx sales  Customer satisfaction Pharmacy Performance Measures

 Patients adherent to med regimen  Achievement of therapeutic goals  Customer satisfaction – care directed  Pharmacists will (and should) be held accountable for contribution to outcomes MTM Quality Measurements – 201?

 Pharmacy Quality Alliance has created consensus- driven quality metrics  High risk meds in the elderly (modified Beers’ list)  Appropriate treatment of HTN in persons with diabetes  Proportion of days covered  ACE/ARB  Statins  Oral diabetes meds  It is expected that CMS will continue to adopt PQA Measures CMS Has Adopted PQA Measures

{ From APhA – Core Elements Pharmacist Services Technical Advisory Coalition – National provider number: Pharmacy Quality Alliance: Pqaalliance.org Resources

 MTM programs represent a significant tool to improve health  The ROI is positive and other health benefits have been documented  Part D plans are evaluated on quality metrics that may be influenced by MTM – pharmacists will also likely be held accountable – Medicare is paying the bill!  Pharmacists can embrace the opportunity to make a difference with MTM Summary

Companies like Mirixa and Outcomes MTM: A. Provide MTM services directly to patients B. Act as Part D providers C. Act as middle men to distribute MTM patients to pharmacists for Part D providers D. Offer NPI numbers to pharmacists

Which of the following is true? A. Patients have not been shown to be satisfied with telephonic MTM services B. The ROI associated with MTM services is insignificant C. A large study demonstrated a survival benefit with MTM services D. None of the above are true

Quality measures related to MTM and Part D drug programs deal with: A. Adherence to regimens B. Proper evidence- based pharmacotherapy C. Safe medication use D. All of the above