The Value of Medication
Therapy Management
Services
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
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
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
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
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
Medication Therapy Management Process
 Today’s wants
and needs
 Responsibility
to participate
in information
sharing and
decision making
 Evaluate appropriateness, effectiveness,
safety, and compliance with medications
 Identify drug therapy problems
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
Experienced Decision Making
Patient
Medication Experience
ASSESSMENT
Practitioner
 Philosophy of Practice
 Social Obligation
 Responsibility to
identify, resolve,
and prevent
drug therapy
problems
 Patient-centered
approach
 Caring
Therapeutic Relationship
MTM Pharmacist/Prescriber
Relationship
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
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
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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
Studies Illustrating
Value of MTMS
• Asheville Project: Diabetes
• Asheville Project: Asthma
• Diabetes Ten City Challenge
• Minnesota Experience Project
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.
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.
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
Mean Cost / Patient / Year
Asheville Total Health Care Costs1
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Baseline
1
2
3
4
Follow-up Year
Medical $
Diabetes Rx
Other Rx
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
5
Average Annual Diabetic Sick-Leave Usage
(City of Asheville)
14
12.6
12
10
8.46
8
6
5.68 5.81 5.67 6.01
6
4
2
6
Y
ea
r
5
Y
ea
r
4
Y
ea
r
3
r
Y
ea
r2
Y
ea
1
r
Y
ea
B
as
el
in
e
0
APhA. Pharmacists Improving Care and Reducing Costs for
Your Plan Participants. Available at: www.pharmacist.com
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.
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.
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.
Economic Outcomes of MTMS
The Asheville Project - Asthma
14
12
10
Percentage
% Patients with
ER/Hospital Events
8
6
4
2
0
BY3 BY2 BY1 Y1
Y2
Y3
Y4
Bunting BA, Cranor CW. JAPhA. 2006; 46:133-147.
Y5
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
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.
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.
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 selfmanagement goals
– Recommended changes in therapy when appropriate
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
10 City Challenge Economic
Outcomes after Year 1
9
8
7
6
Cost in 5
Millions 4
3
2
1
0
Baseline
Year 1
Projected
Year 1
Actual
Medical
Costs
Medication
costs
Pharmacy
Total
Services Health Care
Costs
Costs
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
10 City Challenge Clinical
Outcomes after Year 1
Percentage of
Participants
100
90
80
70
60
50
40
30
20
10
0
DTCC Baseline
DTCC Year 1
A1C testing
A1C <9%
A1C <7%
Lipid testing
LDL <
BP <130/80 Eye exams Flu vaccine Foot exams
100mg/dL
HEDIS process measures for patients with diabetes
Fera T., Bluml BM, Ellis WM. JAPhA. 2009; 49(3): 383-391.
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.
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
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
Economic Outcomes from the
Minnesota Experience Project
$12,000
$10,000
1 Year
before
MTM
$8,000
$6,000
1 Year
after
MTM
$4,000
$2,000
$0
Facilities
(-57.9%)
Professional
(-11.1%)
Prescriptions
(+ 19.5%)
Total Cost
(-31.5%)
Clinical Outcomes from the
Minnesota Experience Project
80
% of patients70
meeting 60
HEDIS goals 50
40
30
MTM Group
No MTM
20
10
0
Hypertension
HTN
n = 254;
p=0.03
Dyslipidemia
Dyslipidemia
n = 254;
P=0.001
Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211
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
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
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.
Elements of MTMS Plan Design
• Eligibility
• Reimbursement structure
• Member engagement strategy
– Incentives
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
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
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
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