1. The Value of Medication Therapy Management Services

2. 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

3. 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

4. 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

5. 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

6. 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 APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

7.  Evaluate appropriateness, effectiveness, safety, and compliance with medications  Identify drug therapy problems Experienced Decision Making Practitioner Medication Experience 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

8. MTM Pharmacist/Prescriber Relationship

9. Pharmacist’s Communication with other Health Providers MTM 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

10. Medications Recommendations MTM 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

11. APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

12. 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

13. Studies Illustrating Value of MTMS Asheville Project: Diabetes Asheville Project: Asthma Diabetes Ten City Challenge Minnesota Experience Project

14. 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.

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

16. Clinical Outcomes of MTMS The Asheville Project - Diabetes Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173–84. American Pharmacists Association

17. Asheville Total Health Care Costs 1 Cranor CW, Bunting BA, Christensen DB.. J Am Pharm Assoc. 2003;43:173-84. APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

18. Average Annual Diabetic Sick-Leave Usage (City of Asheville) APhA. Pharmacists Improving Care and Reducing Costs for Your Plan Participants. Available at: www.pharmacist.com

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

20. 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 program Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

21. 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.

22. Economic Outcomes of MTMS The Asheville Project - Asthma Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

23. Clinical Outcomes of MTMS The Asheville Project - Asthma Improved Asthma control sustained over 5 years Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147. American Pharmacists Association

24. Key Findings: Asheville Asthma Economic benefit –Decreased percentage of asthma patients requiring emergency and hospital care Clinical benefit – Improved asthma control sustained over 5 years (as evidenced by FEV1 measurements) Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.

25. 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.

26. 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 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

27. 10 City Challenge Economic Outcomes after Year 1 Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

28. 10 City Challenge Clinical Outcomes after Year 1 HEDIS process measures for patients with diabetes Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

29. Key Findings: 10 City Challenge Economic benefit –Total health care costs were less than predicted –Prescription costs increased, but overall health care costs decreased Clinical benefit – Increased percentage of patients meeting HEDIS process measurement goals for patients with diabetes Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.

30. 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

31. 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 Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

32. Economic Outcomes from the Minnesota Experience Project

33. Clinical Outcomes from the Minnesota Experience Project HTN n = 254; p=0.03 Dyslipidemia n = 254; P=0.001 Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

34. 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 $8197 Clinical benefit –The MTM intervention group had a higher percentage of patients meeting HEDIS goals for hypertension and dyslipidemia Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

35. 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

36. 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):203-211. Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147. Cranor CW, Bunting BA, Christensen DB. J Am Pharm Assoc. 2003;43:173-84.

37. Elements of MTMS Plan Design Eligibility Reimbursement structure Member engagement strategy –Incentives

38. 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

39. 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

40. 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

41. 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