Medication Therapy Management Jessica Sipe, PharmD Bartell Drugs Community Pharmacy Practice Resident March 1, 2011

Objectives Define Medication Therapy Management (MTM) Identify the essential components of MTM Give real-life examples of MTM services Explain the importance of pharmacist involvement in MTM services

What is MTM?

Medication Therapy Management Services that assure medications are used to – “Optimize therapeutic outcomes through improved medication use” – “Reduce the risk of adverse events, including adverse drug interactions”

Why is MTM needed? Medication-related problems are a massive public health issue in the U.S. A 2009 report by NACDS and NCPA found that only half of patients are compliant with their prescription drug regimen – An estimated 1.5 million preventable adverse events occur year – Overall cost of poor medication adherence runs as much as $290 billion per year 13% of the nation’s total health care expenditures

Where did MTM come from? MTM is not a new service Some components are already done daily by most pharmacists In the 1980s and 1990s, pharmacists began developing a systematic process to assess individual patients’ medication therapies Pharmacists started to receive reimbursement for these services as early as 1992

Where did MTM come from? Medicare Prescription Drug Improvement, and Modernization Act of 2003 – Prescription Drug Plans (PDP) must have MTM programs for Medicare Part D medications – The program requires collaboration with a licensed pharmacist or other qualified provider and the patient’s physician(s) – Geared towards specific patients – “targeted beneficiaries” – Ensured that pharmacists received compensation for their services

MTM Participants Pharmacists PatientsPhysicians

Who can benefit from MTM? Everyone! Patients who use: – Prescription medications – OTCs – Herbals and other supplements

Who can benefit from MTM? Patients who may benefit the most: – On several medications – With several health conditions – Who have questions or problems with their medications – Taking medications that require close monitoring – Have been recently hospitalized – Obtain their medications from more than one pharmacy

Who is eligible for MTM Services? Anyone who wants to pay out of pocket Anyone whose prescription drug plan (PDP) will pay for it – In Medicare terms, these patients are “targeted beneficiaries” – Often these patients will be identified for you

Current Targeted Beneficiary Requirements Must have multiple chronic diseases – PDP cannot require more than 3 chronic diseases – PDP can choose to accept any chronic diseases or limit enrollment to specific diseases, but must target at least four of these conditions: Hypertension Heart failure Diabetes Dyslipidemia Respiratory disease Bone disease/arthritis Mental health

Current Targeted Beneficiary Requirements, cont’d Must take “multiple” Part D medications – PDP cannot require more than 8 medications as the minimum “ High” drug costs – Before 2009: patients had to be predicted to spend at least $4000 on medications – 2010 and beyond: patients have to be predicted to spend at least $3000 on medications 12.9% of Medicare Part D members were eligible in 2010.

Activities that could be considered MTM services Performing or obtaining necessary assessments of the patient’s health status Formulating a medication treatment plan Selecting, initiating, modifying, or administering medication therapy Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness Performing a comprehensive medication review to identify, resolve, and prevent medication- related problems, including adverse drug events

Activities that could be considered MTM services Documenting the care delivered and communicating essential information to the patient’s other primary care providers Providing verbal education and training designed to enhance patient understanding and appropriate use of his/her medications Providing information, support services and resources designed to enhance patient adherence with his/her therapeutic regimens Coordinating and integrating medication therapy management services within the broader health care- management services being provided to the patient

Questions so far?

Providing MTM Setting – Institutional – Ambulatory/community Two types of MTM – Point-of-care – Comprehensive Medication Review Payment for services is ideally based on the time, clinical intensity and resources required to perform the services

What happens during an MTM Service?

Point-of-Care MTM Typically related to a specific medication product Involves identifying potential problems during the normal workflow of the pharmacy (i.e. at the “point of care”) Interventions are on-going and may occur at any time Examples: – Formulary management – Monitoring medication compliance – Assessing need for new care – Providing patient education on new medication with follow-up

Comprehensive Medication Review Patient-focused interview between the patient and the pharmacist – Review all medications (prescription, OTC, herbal, supplements) – Identify, resolve, and prevent medication-related problems – Improve medication therapy and disease management Must be offered yearly to all targeted beneficiaries 3 parts: – Pre-work-up – Patient Interview/Consultation – Follow-up

Pre-Work-Up Initial review of medications (preparing for the consultation): – Drug Interactions – Cost-saving opportunities – Therapeutic Duplication/Suboptimal therapy – Appropriateness of therapy – Over-use/Under-use of medications – Insufficient/Excessive dosing – Lab Assessment

Poly-Med Guide List of patient’s medications sorted by disease state – Drug, strength, and quantity prescribed – Directions – Refill history – Comments/Questions/Concerns Counseling points Side effects Efficacy of therapy Monitoring Compliance/Frequency of use Cost-savings opportunities Administration/technique

Consultation Face-to-face or by telephone – Face-to-face interaction is preferred Clarify allergies and medical conditions Assess – Medication use/adherence – Side effects and efficacy – Goals of therapy and progress – Understanding of medication therapy – Administration technique

Consultation Other issues to assess and address – Patient’s healthcare priorities Cost Comfort – Minimizing side effects Convenience – Simplifying therapy – Language barriers – Literacy level – Cultural Issues

Follow-up Provider – Document care provided – Collaborate with provider to find solutions to medication therapy issues Patient – Provide master medication list – Propose a medication action plan to: Address identified problems Maintain self-management efficacy – Assess improvement/decline in therapy – Address additional questions/concerns

Any Questions So Far?

MTM Platforms For billing and documentation – May also help assess medication problems Generally internet-based MirixaPro™ – Face-to-face CMR; $100 – Telephone CMR; $60 – Flat-fee reimbursement only Outcomes Pharmaceutical Health Care™ – CMR (face-to-face only); $50 – Can bill for subsequent claims resulting from CMR

Outcomes TM Classification of Pharmacist Interventions A.Drug Therapy Problems – Indications Needs Therapy Unnecessary Therapy – Efficacy Suboptimal Drug Selection Insufficient Dose/Duration – Safety Adverse Drug Reaction Drug Interaction Excessive Dose/Duration B.Compliance Assessment – Overuse – Underuse – Admin/Technique C.Cost Efficacy Management D.New/Change Prescription or OTC Therapy E.Other

Outcomes TM Classification of Results A.Drug Therapy Problems  Indications o Initiated Therapy o Discontinued Therapy  Efficacy o Changed Drug o Increased Dose/Duration  Safety o Altered Regimen/Change Drug o Decreased Dose/Duration B.Compliance Assessment  Altered Compliance  Altered Admin/Technique C.Cost Efficacy Management  Initiated Cost Effective Drug D.New/Change Prescription or OTC Therapy  Therapeutic Success  Therapeutic Failure E.Other Patient refusal or prescriber refusal are also potential results of pharmacist interventions

Outcomes TM Billing: ECA levels The significance of MTM services is reported to Outcomes TM via estimated cost avoidance (ECA) levels. Justification must be provided by the pharmacist The claim is reviewed to be sure that the ECA level is reasonable. Each ECA level has an associated ECA dollar amount tied it which approximates the cost of future pharmaceutical, medical, and/or hospital-related costs that would have likely resulted had the MTM intervention not taken place. Based on a cost of illness model & updated annually for inflation.

Outcomes TM Billing: ECA levels Refusal: Patient/Prescriber Refusal Level 1: Improved Quality of Care Level 2: Drug Product Costs Level 3: Additional Physician Visit Level 4: Additional Prescription Order Level 5: Emergency Room Visit Level 6: Hospital Admission Level 7: Life Threatening

Where is MTM going? The Medication Therapy Management Empowerment Act of 2011 – Would increase the number of seniors eligible under Medicare Part D for MTM services – Patients would only need one chronic condition, such as heart disease, to be a targeted beneficiary – Introduced by Sen. Kay Hagan (D, NC) and co- sponsored by Sens. Al Franken (D, MN), Sherrod Brown (D, OH) and Tim Johnson (D, SD) – Introduced on Feb 3, 2011 and referred to the Senate Finance Committee

Where is MTM going? Many leaders in pharmacy circles see MTM as the future of the profession – But pharmacists need to make time for it and integrate MTM into their everyday activities Where ever you take it – get involved! – Participate in student legislative days – Get involved in pharmacy organizations at the local, state and national level – Prove to patients, physicians and other providers that pharmacists are the best- equipped to offer MTM services

Conclusions MTM is an important tool to optimize therapeutic outcomes It’s important for pharmacists to take advantage of opportunities to provide MTM – Use your clinical skills – Get valued for your expertise – Get recognized and paid for your services

Additional MTM Resources American Pharmacists Association: –  MTM Central UW Pharmacy Cares: – sop.washington.edu/pharmacy-cares sop.washington.edu/pharmacy-cares Association of Managed Care Pharmacists: – Center for Medicare & Medicare Services: – _mtm.asp _mtm.asp Washington State Pharmacy Association: –

Pre-lab MTM Activity Pass/Redo Assess patient eligibility for MTM Complete a CMR for a patient – Work-up with poly-med guide – Patient interview and consultation – Follow-up with patient No Homework!

Questions?