Healthcare Transformation Learning Session
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www.hcgc.org
October 22nd Webinar, 1:00 - 2:00 PM
Learning Topic: How pharmacists are expanding their roles to improve value-based healthcare.
Featured speakers:• Jim Gartner, Vice President Pharmacy and Medical Management Services,
CareSource• Kelli Barnes, Assistant Professor of Clinical Pharmacy, The Ohio State
University General Internal Medicine• Emily Vrontos, Specialty Practice Pharmacist, Department of Family
Medicine, The Ohio State University
The expanding role of the pharmacist
Jim Gartner RPh, MBACareSource
10 28 2014
Why did we want to launch a MTM program?
Assist with High Risk members
• Improved quality
Assist with driving HEDIS results
Appropriate medications
• Generic alternatives• Reduce interactions• Reduce inappropriate medications
Preferred Drug List
Positively engage pharmacy network
• Generally see a 2.5-3:1 ROI = MCR
Drive costs savings
MTM Program Approach
• As a part of the MTM program, CareSource members are eligible for a full menu of covered services, which include: 1. Comprehensive Medication Review 2. Prescriber Consultation 3. Patient Adherence Consultation 4. Patient Education & Monitoring
• Members receive MTM coverage through a network of more than 85,000 local pharmacists nationwide, including nearly 3,300 pharmacists in Ohio alone.
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CareSource Pharmacy Network• Statewide kick-off tour to promote the MTM
opportunity within Medicaid– Collaboration with Ohio Colleges of Pharmacy
and Ohio Pharmacy Association – Ongoing support from OutcomesMTM
Network Performance team – Team dedicated to providing the necessary
support, encouragement and resources pharmacists need to operationalize MTM locally within a community
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Year-One Results• In the first 12-months of the CareSource MTM
program:– Total MTM Services Delivered 106,239
– Consultations provided that helped members avert events such as ER visits, hospitalizations and life-threatening complications2,246
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Key Activity in Ohio
Total Patients 122,413
Total Claims 281,209
TIP Claims 35%
Pharmacist Driven Claims 65%
Total Acting MTM Pharmacies 2,420
Estimated Cost Avoidance (AIM) $57,029,321
ROI 1.57:1(Year 1) $ 3,483,523.63 actual cost savings
July 1, 2012 – June 30, 2014
Key Activity in Ohio Claim Type
CMR 20%
Patient Ed/Monitoring 28%
Adherence 35%
Prescriber Consultation 17%
Prescriber Refusal 7%
Patient refusal 37%
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Year 2 Results• Analysis is still in works; however,
showing similar 4:1 ROI.• Savings are driven by reduction of
hospital avoidance– Then ED avoidance
• Drug product cost savings are still being determined.
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Year 2 Results• CMR before and after review completed
– 4500 CMRs reviewed– 12 months utilization before and after
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Utilization PMPM Change
RX Cost Increase 13%Inpatient Cost Decrease 6%Outpatient Cost Increase 9%Professional Cost Decrease 3%Dental Increase 1%ER Rate Decrease 11%
MTM Activities
MTM – CMR intervention after
discharge
Asthmatic patients not on therapy
Children on excessive anti-psychotic RX
Pharmacists in clinic settings
High Risk Case Management referral
MTM StoriesMedication
Adherence and monitoring of BP a
concern for member
Pharmacist worked with
member to obtain a BP monitor and
explained use
Pharmacist explained
importance of adherence and
provided a pill box and set up weekly check points for member to show
pharmacist status of taking
medications
MTM StoriesMember prescribed
multiple medications; two identified as able to
be discontinued
Used two medications from same class; NSAIDs
MTM StoriesDiabetes medication review• Discussed losing weight• Adherence of medications• Monitoring Blood Sugars
Member was not using Inhaler and Stomach
Medication (discontinued)
Member StoriesMember with 9
disease states and 20 medications
Has asthma; shortness of
breath
Incorrectly using maintenance inhaler
Need identified forrescue inhaler
Case Findings• Pharmacists have become health coaches• The CMR conversation leads to greater
findings• Pharmacists truly part of the health care
team• CareSource members move to the head of
the line• Pharmacists are able to practice at a high
level of the profession
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Reimbursement Model
• Pharmacies are no longer achieving strong reimbursement for dispensing of RXs
• Need to move to service model• Current MTM Model
– $10.00 Successful Patient Education and Monitoring
– $20.00 Successful Physician Outreach– $75.00 Complete Medication Review– $2.00 for trying
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Reimbursement Model
• Pay for Performance for pharmacists will be an evolution
• Achieving success with MTM model will only lead to greater P4P success
• Reimbursements– Health Coach– Blood draws– Vaccinations
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Pharmacist Collaboration to Maximize Value-based Healthcare
Kelli Barnes, PharmD, BCACPEmily Vrontos, PharmD, CDE
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General Internal Medicine Clinics
Martha Morehouse GIM Clinic CarePoint East GIM Clinic Stoneridge GIM Clinic Grandview GIM Clinic Hilliard GIM Clinic Lewis Center Primary Care
National Committee for Quality Assurance (NCQA) tier 3 patient-centered medical homes (PCMH)
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Family Medicine Clinics
Bethel Road FM Upper Arlington FM CarePoint East FM Rardin FM CarePoint Gahanna FM Worthington FM CarePoint Lewis Center FM New Albany Primary Care
National Committee for Quality Assurance (NCQA) tier 3 patient-centered medical homes (PCMH)
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Clinic Personnel
Attending physicians and residents Pharmacists and pharmacy residents Nurse practitioners Care coordinators (RN) Social workers Medication assistance program coordinator Medical assistants
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Disease State Management
Population Management
Transitional Care Management
GIM Interdisciplinary Diabetes Clinic
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Patient referred by
PCP
Patient interviewed
by pharmacist and physician
Shared Plan making, goal
setting
Pharmacist provides follow-up
between visits
Pharmacist delivers patient
education
Physicians follows labs,
communicates with PCP
Diabetes Clinic Outcomes
Baseline Most Recent7.5%
8.0%
8.5%
9.0%
9.5%
10.0%
10.5%
p < 0.001
Average Between Readings 333 + 138 days
Hem
oglo
bin
A1c
p < 0.001
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Diabetes Clinic Value
• 10-14 patients scheduled per clinic (½ day)• 1 Attending physician, 2-3 medical residents, 2 pharmacy
residents, 1 pharmacist• Billed as 99213 or 99214 visit• PCP can focus on other patient needs• Interprofessional education
• Could be modified to pharmacist-only clinic
PCP: Primary Care Physician
Family Medicine Diabetes Visits
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Patient referred by
PCP
Appointment scheduled for 1:1 education/ management
Goal setting, medication
management
New Service: group visit referral if
appropriate
Labs ordered/reviewed RPh
and PCP
Pharmacist follow-up
between PCP visits
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FM Diabetes Visits
5-6 patients scheduled per half day Billed as 99211 Attending physician collaborates for medication
recommendations Interprofessional education
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Other Disease State Management Offered
General Internal Medicine Polypharmacy clinic Anticoagulation clinic Pharmacy appointments
Family Medicine Polypharmacy appointments
Multiple medications/disease states Renal/hepatic impairment Adherence
Smoking cessation Hypertension/hyperlipidemia education
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Shared Disease State Management
Population Management
Transitional Care Management
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Population Management
Identify population
Generate report
Intervention
Track Outcomes Update EMR
CKD managementRenal Medication Dosing
Patients with eGFR < 60 mL/min/1.73m2
Pharmacist InterventionPhysician Collaboration
Laboratory monitoringMedication Dosing
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Population Management: CKD Outcomes
Medications Not Requiring
Renal Adjustment
Medications RequiringRenal Adjustment
N = 270 (14.1%)
MedicationsRenally Adjusted
Medications Not Renally Adjusted
N = 1,645 (85.9%)
N = 138(51.1%)
N = 132 (48.9%)
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N = 138(51.1%)
N = 132 (48.9%)
Population Management: CKD Outcomes
Medication NOT renally dose adjusted
Medication renally dose adjusted
Before Pharmacist Intervention After Pharmacist Intervention
N = 233 (86.3%)
N = 222 (82.2%)
N = 49 (17.8%)
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Population Management Opportunities
• Preventative health• Chronic disease state management• High risk medication monitoring• Collaboration with Care Coordinators for identifying
patients with diabetes, current smokers• Comprehensive medication reviews for CareSource and
Ohio State University Health Plan patients
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Population Management Value
• Decrease physician time spent during visit• PCMH credentialing• Improved disease state or preventative health outcomes• Potential decrease in adverse drug events
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Shared Disease State Management
Population Management
Transitional Care Management
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Transitional Care Management
• 99495/99496 introduced in January 2013• Contact by “licensed clinical staff” within 2 business
days of discharge from acute care setting
Type of contact• Phone• Email• Face-to-face
• Face to face visit with physician within 7-14 days• Continued coordination 30 days post-discharge• Reimbursement for physician visit ~50% higher if TCM
performed
Acute Care Setting• Acute or rehabilitation hospital• Observation unit• Nursing facility
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GIM Transitional Care Management Workflow
Patient Discharged• D
ischarge summary sent to physician
Physician review to determine complexity• M
essage electronically sent to pharmacist
Pharmacist contacts within 2 business days• A
ssess patient; medication reconciliation; confirm appointments; document
Patient follow-up within 7 or 14 days• P
harmacist’s note leads to focused visit
GIM Transitional Care Coordination
Not Scheduled Scheduled
Scheduled
Follow up visit scheduled PRIOR to TCC
Follow up visit scheduled After TCC
NotScheduled
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Summary
Primary care practice comprised of chronic disease and medication management
Pharmacists have unique training to assist in medication management
Emerging models provide value/incentive to include pharmacists in PCMH practices
Pharmacist Collaboration to Maximize Value-based Healthcare
Kelli Barnes, PharmD, BCACPEmily Vrontos, PharmD, CDE
Healthcare Transformation Learning Session
www.hcgc.org
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or reflections
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THANK YOU!
www.hcgc.org
Lead Support Major Support Additional Support
100% of ourBoard of Directors
& Staff
Individual & CorporateDonations
• Thank you for joining us today!
• Thanks to our speakers!
• Thanks to our funding partners!
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Please save the date for our last learning session of 2014!
Sharing lessons learned from implementing best practices in Greater Columbus
Friday, December 5, 8:00-11:30 AM
The Nationwide & Ohio Farm Bureau 4-H Center, 2201 Fred Taylor Dr. Columbus, OH 43210