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Copy of The Different Layers of Medication Therapy Management

Applying the core elements of MTM to practice

Anna Vaysman

on 3 March 2013

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Transcript of Copy of The Different Layers of Medication Therapy Management

The Winding Road of MTM
Anna Markel Vaysman, PharmD
March 5, 2013 Objectives List the key goals of MTMS identified by the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003
Identify the clinical, economic, and humanistic outcomes that have been proven to be associated with MTMS
Explain the core elements of the MTMS model
Apply MTMS core elements to patient case What is the big deal? Reimbursement based on value of service
Medicare Part D
Administered by private insurers
MMA didn’t define MTM services, standards of providing care, or performance measures
Encouraged prescription drug plans to develop their own programs (including: what, who, when, how much)
Data collection from these models will be used to set “best practices” MMA of 2003 What is it?
Passed in by Congress in 2006
Medicare Part D
Entitled seniors and other Medicare beneficiaries to receive MTM services at high-risk for medication-related problems
Who qualifies for MTM under Part D?
Multiple chronic diseases
Take multiple Part D drugs
Incur annual cost of Part D drugs >$4,000 MTM Providers for Part D Plans
Results from 2008 MTMPs Can utilize internal and/or outside personnel
49.3% utilized in-house staff
27.7% outside personnel
23% combination of both
Can utilize pharmacists, physicians, registered nurses, and/or others
98.2% pharmacists
40.4% physicians
50.7% nurses
32.4% others? Why Does Congress care? Medicare population:
65 years of age or older
Average of >5 medications
Result: increased risk of medication related issue
Over past 10 years number of prescription drugs dispensed has increased 60% Why Does Congress care? < 50% patients adherent to medications after 12 months, resulting in poor outcomes
Estimated 125,00 deaths per year
10% of all hospitalizations
23% of nursing home admissions
Increase in preventable adverse drug related events resulting in increased costs to health care system
$ 76.6 billion in 1995
$177.4 billion in 2000 Asheville Project 2003 Clinical
A1C: improved at each f/u visit (57.7-81.8%)
LDL-C: decreased at each f/u visit (50-66.7%)
Annually, >50% of patients had decline of >10% of insurance claims
Increase in Rx costs
Overall: total mean direct medical costs PPPY decreased annually compared to baseline
Decrease mean # of sick days annually
Estimated value of productivity increased by $18,000/yr
Employer savings between $1,622 and $3,356 PPPY MTMS-The Minnesota Experience Clinical
Identified 2.2 drug related problems/patient
40% indication, 30% effectiveness, 20% safety, 10% adherence
78% resolved w/o MD involvement, 22% w/ collaboration
Hypertension management (HEDIS 2001 standard)
71% intervention group vs. 59% control (p=0.003)
Hyperlipidemia management (HEDIS 2001 standard)
52% intervention group vs. 30% control (p=0.001)
Total annual health expenditures PPPY declined 31.5%
Rx drug expenditure increased 19.7%
Overall: ROI was found to be $12.15 per $1 in MTM costs MTM different from OBRA ’90? OBRA ’90
Counseling is brief
Medication use/directions/pt questions
Doesn’t take into account other pt meds
Focus on medication related issues through “core elements” of MTM services
Assessment of ALL pt medications/conditions
Assessment of problems/development of intervention/documentation/follow-up/interaction with other health care providers History of MTM Core Elements of MTM 1 1 2,3,4 2,3,4 4 5 6
Total healthcare costs were reduced by $1,079 PPPY
A1c decreased 7.5% to 7.1% (p=0.002)
LDL decreased 98 to 94 mg/dL (p<0.001)
SBP decreased 133-130 mmHg (p<0.001)
Influenza vaccine increased 32% to 65%
Eye exams increased 57% to 81%
Foot exams increased from 34% to 74% Diabetes Ten City Challenge MTM Clinic at UI Health “Refill 10”: ~1995
PCC Pharmacy patients with > 10 medications
Meds refilled prior to patient’s arrival
Over time clinical services added to patients care

“Refill 10”: 2001
First PharmD hired to provide solely clinical services
Program evolved into referral-based, comprehensive MTM program

“Refill 10”: 2004
Changes in Medicare ------> name change to UIMC MTM Clinic Clinic History MTMC’s Vision:
We will lead in medication therapy management through innovation, education and research to decrease hospitalizations, improve healthcare utilization, reduce costs and improve patients' quality of life.

MTMC’s Mission
Reconcile and optimize medication regimen
Prevent and monitor for ADEs
Improve medication adherence
Promote preventative care
Collaborate with healthcare providers to manage disease states
Reduce medication cost MTMC Vision and Mission Current Staff
3 full-time PharmDs (80% of time in clinic)
4 part-time PharmDs (split time between MTM and another clinic)
Heart Center, Endocrinology, Psychiatry, Pulmonary
ALL PharmDs are faculty at UIC College of Pharmacy
1 full-time MTM technician
P4 students, UIC PGY-1, Community PGY-1, AmbCare PGY-2 residents UI Health MTMC Dr. Lori Wilken (MTM/Pulm) Dr. Jessica Tilton – Operations Manager
(MTM/Heart Center) Dr. Shiyun Kim (MTM/Endo/Psych) Dr. Daphne Smith-Marsh (MTM/Endo) Dr. Shah (MTM) Dr. Anna Markel Vaysman (MTM) Dr. Tiffany Scott-Horton (MTM) Facility Description
Embedded in Outpatient Care Center Pharmacy
Hours: Monday-Friday 9AM-5PM
MTM space
3 cubicles (soon to be 4) with computers
TWO consultation rooms
Each room has: desk/computer/2 chairs
Monitoring logs/laboratory slips
Blood Pressure monitor
Soon to come: POCT – Glucose monitoring, A1c UI Health MTMC - Facility Description MTM Description
5 Service Areas
6th Service Area (grey area)
DISEASE STATE MANAGEMENT UI Health MTMC MTMC: Referral from UIC Healthcare Provider
Multiple medications, diseases, healthcare providers, diminished coordination of care
Difficulty self-managing medications
Difficulty adhering to long-term medication regimens
Significant lack of medication understanding
Agree to have their medications filled at UIC pharmacy
Currently in “Margin for dispensing” UI Health MTMC Baseline Visit
Patient assigned to primary PharmD  responsible for patient
Allows for continuity of care
Goal: Patient to see primary PharmD ~80% of the time
This visit focused on COLLECTING INFORMATION
Review EMR (med history, diagnosis, number of providers, labs, demographic data, meds put in by various providers)
Identify RED FLAGS to address immediately
Will also INTERVIEW patient
Explain program (admission is voluntary)
Patient given MTM folder
Health Assessment Form, Informed-Consent, Rights and Responsibilities UI Health MTMC: Conducting Baseline Visit Baseline Visit: Medication Reconciliation
Bring ALL home meds (even those not taking, OTC products)
Compare home meds to EMR
At end of visit will provide “Patient Friendly Medication List”

Baseline Visit: Action/Plan
Address adherence concerns
Address immediate concerns
Schedule follow-up visit UI Health MTMC: Conducting Baseline Visit Routine Visit
Usually monthly: to coordinate with medication refills
More often if needed
Insulin titration
New therapy initiated (Ex: BP meds)
Psych patients: weekly visits until adherence improves
Coumadin patients: coincide with INR checks UI Health MTMC: Conducting Routine Follow-Up Visit Routine Visit: Preparation
1 week before visit review EMR
Medication changes? ER/hospitalizations?
390 students complete medication refill sheets
Give to OCC pharmacy to process and fill
Med issues such as RTS, no refills are identified prior to visit
MTM technician fills PILL BOXES
60% patients require pill boxes (8 PB provided at baseline visit)
Checked by PharmD UI Health MTMC: Conducting Routine Follow-Up Visit UI Health MTMC: Routine Visit Preparation Routine Visit: Patient Interview
Address/review chronic disease states
Identify new problems
Assess adherence
Evaluation patient’s response to therapy
Identify drug related problems
Evidence based monitoring and guidelines: (Ex: BP, BG review)
Take appropriate steps in EMERGENCY issues (ER, RPM clinic)
Contact appropriate provider to address medication related issues
Patients ALWAYS receive “Patient Friendly Medication List”
SOAP notes ALWAYS in EMR UI Health MTMC: Conducting Routine Follow-Up Visit Failed appointments
3 calls
2 Failed letters
1 Discharge letter (after ~60 days patient considered inactive)
In 2008 calculated that ~7% patient lost to follow-up
Other common reasons for leaving MTM
Nursing home placement
Death UI Health MTMC Average Monthly Prescription Charge
$800-900 per patient per month
Top Diagnosis
A. Fib
Coronary Artery Disease
Heart Failure
Thrombotic Disorders
Constipation UI Health MTMC: Clinical Data 2008 Am J Health-Syst Pharm - Volume 65 May 1, 2008 Data from 2006/2007 (N=140)
Description Mean (range)
Patient age: 64 (35-93)
Number of diagnosis: 9.6 (4-15)
Number of visits/pt/mo.: 1.3 (0.6-3)
Number of meds/pt: 15.3 (8-28)
Number of daily doses/pt: 20 (8-33)
Gross revenue from rx/pt/mo.: 300 (225-339)
Number of rx filled/mo.: 1800 (1740-2085) UI Health MTMC: Clinical Data 2008 Am J Health-Syst Pharm - Volume 65 May 1, 2008 Qualities and Competencies of MTM pharmacist
Accept responsibility for patient needs
Excellent communication skills
Excellent listening skills (verbal and non-verbal)
Problem solving-skills
Didactic knowledge and clinical sills
ALL PharmDs residency trained, 3 CDE, 2 BCACP, 1 BCPS)
Recognize knowledge/training limitations: referrals
Organization skills/ability to prioritize and multitask
Ability to HAVE FUN!!! UI Health MTMC Clinician UI Health MTMC 2001: 30 active patients NOW: 150 active patients 1. Medicare Part D Medication Therapy Management Programs 2008 Fact Sheet. Available at http://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet.pdf. Revised March 19, 2008. Accessed July 18, 2009.
2. National Association of Chain Drug Stores. Retail sales figures for traditional chain drug stores 1986-2005. Available at http://nacds.org/wmspage.cfm?parm1+508. Accessed July 10, 2009.
3. Pellegrino AN, Martin MT, Tilton JJ, et al. Medication Therapy Mangement Services: Definitions and Outcomes. Drugs
4. 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 (2): 173-84.
5. Isetts BJ, Schondelmeyer SW, Artz MA, et al. Clinical and economic outcomes of medication therapy management services: The Minnesota experience. J Am Pharm Assoc. 2008; 48: 203-211.
6. Early Successes of Diabetes Ten City Challenge Reported as APhA 2008
7. Chater RW, Moczygemba LR, Lawson KA, et al. Building the Business Model for Medication Therapy Management Services. J Am Pharm Assoc. 2008; 48 (1): 16-22.
8. Medication Therapy Management in Pharmacy Practice: Core Elements of MTM Service Model (Version 2). March 2008. Accessed July 18, 2009.
9. Delivering Medication Therapy Management in the Community. American Pharmacist Association. August 2007 Edition.
10. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medication therapy management services. J Am Pharm Assoc. 2009; 49: 51-58.
11. DaVanzo J, Dobson A, Koenig L. Medication Therapy Management Services: A Critical Review. J Am Pharm Assoc. 2005; 45: 580-587.
12. Schommer JC, Planas LG, Johnson KA, et al. Pharmacist-provided medication therapy management (part 2): Payer perspectives in 2007. J Am Pharm Assoc. 2008; 48: 478-486.
13. Schommer JC, Planas LG, Johnson KA, et al. Pharmacist-provided medication therapy management (part 1): Provider perspective in 2007. J Am Pharm Assoc. 2008; 48: 354-363.
14. Millonig MK. Mapping the route to medication therapy management documentation and billing standardization and interoperability within the healthcare system. J Am Pharm Assoc. 2009; 49 (3): 41-50.
15. Tice B. What’s in Store for MTM. Chain Drug Review. 2008; 30.14: 52-59.
16. Nau DP. Quality Measurement: Time to Get Serious. J Am Pharm Assoc. 2006; 46 (6): 668-678.
17. Department of Health and Human Services-Centers for Medicare and Medicaid Services. Medicare Rx Update: April 19, 2006. Pharmacy quality alliance…now a reality (online). Available from URL: http//www.cms.hs.gov/Pharmacy/downloads/update041906.pdf. Accessed July 23, 2009.
18. Schlaifer M, Carson AF, Mangum A, et al. Sound Medication Therapy Management Programs, Version 2.0 with Validation Study. JMCP. 2008; 14(1): S1-S44. References
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