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TRANSCRIPT
How to Conduct an Effective
Medication Therapy Management Session in the Community
Pharmacy
Presented by:
Dale Christensen, University of North Carolina Susmita Chavala, Humana Ed Staffa, Community MTM
Ramona Edery, Uptown Drug
10:15 a.m. - 11:45 a.m., Tuesday, October 10, 2006 Las Vegas, Nevada
Evaluation # 06-153
This program is approved by NCPA for 0.15 CEUs (1.5 contact hours) of continuing education credit. NCPA is approved by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Dale Christensen Dale B. Christensen is Professor, Pharmaceutical Outcomes and Policy, at the University
of North Carolina School of Pharmacy. His research interests are in the areas of drug
taking compliance, pharmacoeconomics and drug policy evaluation. However his
primary interest is in developing and evaluating pharmacist medication therapy
management services.
He was one of the early researchers in the area of pharmacist cognitive services. In
Washington, he was the PI on a large OBRA-90 demonstration grant to study the effects
of paying pharmacists for value added or cognitive services. In North Carolina, he
supervised the evaluation of the Asheville diabetes disease management project, and
other polypharmacy medication therapy management projects in ambulatory and
nursing home settings. For the past 15 years he has worked with the Medicaid agencies,
both in the state of Washington and in North Carolina on drug-related issues. He has
worked with national pharmacy organizations on the Medication Modernization Act,
and is a frequent speaker on this subject.
Educational Objectives
Presentation Title: Lessons Learned from Community-based MTM Programs to Date Name of Presenter: Dale B. Christensen, Ph.D., R.Ph 1. State 3 characteristics of patients for whom MTM services are required
under the MMA of 2003. 2. Cite one example of a disease-focused MTM-type program 3. Cite one example of a problem-oriented MTM type program 4. Cite one example of a polypharmacy oriented MTM type program 5. State 2 essential components of a successful MTM community-based
program.
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How to Conduct and Effective Medication Therapy Management Session in the Community Pharmacy
October 10, 2006 Panelist:
Dale B. Christensen, R.Ph., Ph.D.
Lessons learned from community based MTM programs to date
Learning objectives:• Briefly review CMS MTM requirements
• Review 3 alternative pharmacist service models and real-world examples of each
• Discuss likely performance and QA measures for MTM services
• Discuss incentives and barriers to providing MTM services
2
MTM definition.. legislative intent
Optimize therapeutic outcomes for targeted beneficiaries through programs designed to:Reduce the reduce the risk of adverse effects and adverse drug interactions. Identify patterns of over and under-useIncrease adherence to prescribed meds
Targeted beneficiaries for MTM
Beneficiaries must meet all 3 criteria:Have multiple chronic diseases (2+)Are taking multiple Part D drugsLikely to incur annual costs for covered Part D drugs of > $4,000 (for 2006)
* It is estimated that 25-30% of enrollees would qualify
3
CMS commentary on MTM (2)
“There should be different levels of service based on the individual pt. requirements. (e.g. a 15 -minute phone consult, up to a 1-hour in-person visit with the RPh).”
“We believe that a competitive market supported by useful information on MTM services will provide the best mechanism for establishing optimal MTM services”.
CMS goal for MTM
Programs will “evolve and become a cornerstone of the
Medicare Prescription Drug Benefit”
4
MTM services- how will they be implemented?
Call centers at PBMs?Pharmacist-nurse case management approach?Pharmacy-specific drug problem ID and resolution activities applied to all eligibles?
Implementation plans and models will differ for MA-PD programs vs. stand-alone PDP programs because of different incentives
Eligible populationTarget patients at risk
Potential drug therapy problems
Call CenterTriage
Est. Rx cost of $4,000 /yr.2+ chronic conditions + meds
How MA-PD plans are likely to provide MTM services
Computer algorithm applied to claims database
nurse case
managerConsultant RPh
Consultant Physician
Primary care providerRPh or physician
5
Approaches to MTM servicesApproaches to MTM services-- ModelsModels
Patients with target diseases(i.e. diabetes, asthma)
Focus:• Assure proper use of drugs
• provide education and training• Assist in disease monitoring
• Teach patient self mgmt.
“Polypharmacy” patientsHigh Rx use, cost, or risk
(patients may have multiple chronic diseases, visit multiple physicians)
Focus:• Reduce high risk drugs
• Reduce duplicate or unnecessary drugs• Achieve more cost effective drug therapy
Rx-related drug problemsdetected at the time of dispensing
Focus:• Identify and resolve potential
drug therapy problems atthe time of dispensing
Examples of poly-pharmacy projects
Ambulatory polypharmacy projects (pilots)
IA Medicaid ambulatory care polypharmacy project.
NC State Employees Health Plan polypharmacy project
NC elderly Medicaid nursing home polypharmacy project
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Iowa Medicaid Pharmaceutical Case Mgt
EligibilityPharmacist: certificated in case mgmt. Must have private consult area, maintain prob. oriented pt record.
Patients: One of 12 chronic disease states, taking 4+ oral Rx’s. Not in nursing home
Claims submitted using CMS 1500 forms. Initial assessment: $75, f/u visit (max: 4/yr)- $40. Prev. assessment (max: 1/6 mo.) - $25.
Equal compensation for physicians and R.Ph.Assessment: Qualitative impact; costQualitative impact; cost
Iowa Medicaid Pharmaceutical Case Mgt...Major findings
About 1 in 4 pharmacies provided “high intensity”services90% of claims were filed by RPhs; 10% by physiciansThe mean medication appropriateness index (MAI) scores per patient decreased significantly at 9 mo. compared to baseline% of patients using high risk meds decreased in high intensity pharmacies vs “low intensity”No difference in health care utilization or charges
Source: Chrischilles et al, JAPhA,2004; 44:337-49.
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NC State Health Plan polypharmacy programTrial program with 3 unique features:
A “brown bag” type medication therapy review Targeted at patients who were the highest Rx drug users Voluntary and free to eligible recipientsGenerous RPh reimbursement
Evaluation objectives: Assess…Types of potential drug therapy problems found and services performed in their resolutionChanges in drug therapy and costs Level of patient satisfaction with services provided
* Sponsored by the Institute for the Advancement of Pharmacy Practice: submitted for publication
NC State Health Plan project results…Potential drug therapy problems
Potential Problems Detected by Pharmacists, by Disease State
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Diabetes HTN Cardio All patients% of paients w ith problem
Potential underuse More C/E drug availableSuboptimal drug Potential overuseOther
8
NC State Health Plan projectResults: Pharmacist Recommendations
Pharmacist Recommendation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Diabetes HTN Cardio All patients
Chronic disease
% o
f pat
ient
s w
ith p
robl
em
Add drug No Change Drug change
Any change Other
NC State Health Plan project results: Educational services provided
0
10
20
30
40
50
60
70
80
90
100
DIABETES HTN CARDIO ALL PTS
% o
f Pat
ient
s re
ceiv
ing
Medication DiseaseCompliance Self-careSelf monitoring device
9
NC State Health Plan project resultsSatisfaction with RPh services
83%“The SHP should offer this service to others”
38%“ I have saved money on my meds.”
38%“ I am now better about taking my meds as
prescribed.”
67%“The RPh cleared up my med problems.”
83%…courteousness and respectfulness of med
concerns”
89%.. the quality of info provided by my RPh”
89%…the eval of meds by my RPh.
94%...time spent by RPh evaluating my meds.
Agree or strongly agreeI am satisfied with…
Examples of a Rx-related problem service model
Patients with target diseases(i.e. diabetes, asthma)
Focus:• Assure proper use of drugs
• provide education and training• Assist in disease monitoring
• Teach patient self mgmt.
“Polypharmacy” patientsHigh Rx use, cost, or risk
(patients may have multiple chronic diseases, visit multiple physicians)
Focus:• Reduce high risk drugs
• Reduce duplicate or unnecessary drugs• Achieve more cost effective drug therapy
Rx-related drug problemsdetected at the time of dispensing
Focus:• Identify and resolve potential
drug therapy problems atthe time of dispensing
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A model for providing DRUG PROBLEM RELATED services when dispensing
IINNTTEERRVVEENNTTIIOONN
Computer Computer SCREENSCREENALERTALERT
RPH RPH Problem Problem
identified, identified, documenteddocumented
RREESSUULLTT
OOUUTTCCOOMMEE
DRUGDRUGRxRx’’dd
RPH ACTIONRPH ACTION
Outcomes Encounter
Documentation:
5 Step Process
1. Reason
2. Action
3. Result
4. ECA
5. Notes
•• Reference what Reference what medications are medications are involved under involved under ““Prescription Prescription Information sectionInformation section””
11
Examples of a Disease-specific MTM model
Patients with target diseases(i.e. diabetes, asthma)
Focus:• Assure proper use of drugs
• provide education and training• Assist in disease monitoring
• Teach patient self mgmt.
“Polypharmacy” patientsHigh Rx use, cost, or risk
(patients may have multiple chronic diseases, visit multiple physicians)
Focus:• Reduce high risk drugs
• Reduce duplicate or unnecessary drugs• Achieve more cost effective drug therapy
Rx-related drug problemsdetected at the time of dispensing
Focus:• Identify and resolve potential
drug therapy problems atthe time of dispensing
The “Asheville Project” Asheville, NC*
Employers:City of Asheville, Mission Health Care SystemInitially targeted at patients with diabetes. Expanded to asthma, hypercholesterolemia
The offer to patients:Co-pay waiver for diabetes drugs and suppliesFree personal glucose monitorMonthly appts with a community pharmacistReferral to Diabetes Education Ctr or physician PRN
RPhs compensated for initial and f/u visits: ($75/$35)
Cranor CW, Bunting BA, Christensen DB. Long-term Outcomes of the Asheville Diabetes Pharmacist Care Project. JAPhA. 2003; 43: 173-84.
12
Figure 1. Percentage of Lab Values in Optimal Range Over Time
0
10
20
30
40
50
60
70
80
Baseline 1st Follow-up
2nd Follow-up
3rd Follow-up
4th Follow-up
5th Follow-up
6th Follow-up
7th Follow-up
Perc
enta
ge o
f Lab
Val
ues
in O
ptim
al R
ange
A1C LDL-C HDL-C
ASHEVILLE PROJECT RESULTS
Asheville Project: Direct Medical CostsOver Time
$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
Mea
n C
ost /
Pat
ient
/ Y
ear
Other RxDiabetes RxMed services
Cranor CW, Bunting BA, Christensen DB. Long-term Outcomes of the Asheville Diabetes Pharmacist Care Project. JAPhA. 2003; 43: 173-84.
13
City of Asheville Medical CostsCity of Asheville Medical Costs
$6,127
$3,554
$5,021$4,535
$3,902$4,651
$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000$8,000
58% savings based on actual 2001 costs vs. expected 2001 costs (1996 costs + annual CPI medical care inflation figures)
1996 1997 1998 1999 2000 2001
$7,248
58%
Source. J. Miall, Director of Risk Management, City of Asheville
Expansion of the Asheville model: Patient Self-Management Programsm First year results*
( avg.: $918 lower than projected)
Total mean H.C Costs104 mg/dl113 mg/dlLipids (LDL-C)
131136Systolic BP
87%57%satisfaction with diabetes care
80%38%Foot Exam82%46%Eye Exam77%52%Flu Shot7.17.9A1c
Followup (6mo-1yr)BaselineDiabetes Care Measure
JAPhA 2005; 45:130.
14
What about MTM-related outcomes?
How will MTM initiatives be evaluated?What will be the yardsticks/benchmarks?
CMS expectations for MTM in 2006
CMS does not expect a rapid uptake into MTM programs
Data to determine those best qualified for MTM will not be known until 2nd or 3rd Quarter of 2006
Data to determine actual health outcomes will not be available until mid to late 2007
16
RESULTof
PHARM CAREINTERVENTION
DRUG THERAPYAPPROPRIATEfor DISEASE
STATE?
PATIENT BEHAVIORAPPROPRIATE?
DISEASEPREVENTED
?
DISEASECONTROLLED
?
MEDICALCARE
UTILIZATION
COST
IMPACT of MTMS interventions on UTILIZATION and COSTS
Eligible populationTarget patients at risk
Potential drug therapy problems
Patients with drug therapy change
recommendations
Patients with drug therapy
changes
Problem rate: % patients with potential drug therapy problems
(PDTP)
Type of problem; interventionrate per patient with PDTP
Drug therapy change rate per patient with R.Ph. intervention;
change rate per PDTP
How to evaluate the impact of MTM
17
Measures of impact of pharmacistservices
Eligible population
Patients with ACTUAL drug therapy problem
Target patients at riskPotential drug therapy problems
Patients with ACTUAL drug therapy problem
IMPACT• ECONOMIC• CLINICAL
• HUMANISTIC
Patients with drug therapy
problemRESOLVED
Economic:Rx: #, $$ Rx PMPM
Physician: # visits, $$ PMPMHospital, ED: # admits, LOS, $ PMPM
ClinicalChange in disease status e.g., b.p, HgA1c, lipids (HDL,LDL)
FEV 1
Humanistic• Knowledge gain• Adherence to Rx drug taking, diet,
exercise, disease self monitoring.• Satisfaction with care• Quality of life (physical, social,
mental functioning)
Carrots and Sticks--incentives andbarriers to providing MTM services
Adequate compensation RPh professional orientation, willingnessOwner-manager attitudes & supportWorking environmentOpportunity to provide services: number of eligible patientsTraining, credentialing
18
Wrap-up….. we discussed
MTM service regs and regulatory intent 3 different MTM service models: 1) Polypharmacy, 2) Rx-related drug problems, 3) Disease-focused,
Real world examples of each model How MTM programs are likely to be evaluatedBarriers and opportunities, incentives and disincentives
Learning Assessment Questions
Presentation Title: Lessons Learned from Community-based MTM Programs to Date Name of Presenter: Dale B. Christensen, Ph.D., R.Ph 1. Which of the following patients are currently required to receive MTM under
CMS guidelines? a. Any patient at the prescriber or pharmacist’s discretion b. Patients taking 2+ covered meds c. Patients having 2+ chronic diseases d. Patients spending > $4,000 on Rx drugs e. b), c), and d) above
2. Which of the following is a good example of a disease-focused MTM
program? a. WA pharmacist CARE project b. Iowa Medicaid pharmaceutical care program c. Outcomes Pharmaceutical Care program d. The Asheville project e. NC LTC project
3. Which of the following is/are good example(s) of a polypharmacy-focused
MTM program? a. WA pharmacist CARE project b. Iowa Medicaid pharmaceutical care program c. Outcomes Pharmaceutical Care program d. The Asheville project e. NC LTC project f. b) and e)
4. Which of the following is/are a good example(s) of a problem-focused MTM
program? a. WA pharmacist CARE project b. Iowa Medicaid pharmaceutical care program c. Outcomes Pharmaceutical Care program d. The Asheville project e. a) and b) above
5. Which of the following is NOT an important component of a successful MTM program ?
a. Prescriber collaboration and support b. Pharmacy manager support c. Pharmacist work environment d. Financial incentive e. Patient incentive f. None; all are important