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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.

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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.

1

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

6

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.

7

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

10

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

Learning Assessment Answers

Presentation Title: Lessons Learned from Community-based MTM Programs to Date Name of Presenter: Dale B. Christensen, Ph.D., R.Ph 1. e

2. d

3. f

4. e

5. f