How to Conduct an Effective Medication Therapy Management Session in the Community Pharmacy

Transcription

1 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 # 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.

2 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.

3 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 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.

4 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 1

5 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-use Increase adherence to prescribed meds Targeted beneficiaries for MTM Beneficiaries must meet all 3 criteria: Have multiple chronic diseases (2+) Are taking multiple Part D drugs Likely to incur annual costs for covered Part D drugs of > $4,000 (for 2006) * It is estimated that 25-30% of enrollees would qualify 2

6 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 3

7 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 How MA-PD plans are likely to provide MTM services Eligible population Target patients at risk Potential drug therapy problems Consultant RPh Call Center Triage Consultant Physician nurse case manager Est. Rx cost of $4,000 /yr. 2+ chronic conditions + meds Computer algorithm applied to claims database Primary care provider RPh or physician 4

8 Approaches to MTM services- Models 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 patients High 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 problems detected at the time of dispensing Focus: Identify and resolve potential drug therapy problems at the 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 5

9 Iowa Medicaid Pharmaceutical Case Mgt Eligibility Pharmacist: 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; cost Iowa Medicaid Pharmaceutical Case Mgt...Major findings About 1 in 4 pharmacies provided high intensity services 90% of claims were filed by RPhs; 10% by physicians The 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:

10 NC State Health Plan polypharmacy program Trial 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 recipients Generous RPh reimbursement Evaluation objectives: Assess Types of potential drug therapy problems found and services performed in their resolution Changes 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 90% Potential Problems Detected by Pharmacists, by Disease State 80% 70% 60% 50% 40% 30% 20% 10% 0% Diabetes HTN Cardio All patients % of paients with problem Potential underuse More C/E drug available Suboptimal drug Potential overuse Other 7

11 NC State Health Plan project Results: Pharmacist Recommendations Pharmacist Recommendation 100% % of patients with problem 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Diabetes HTN Cardio All patients Chronic disease Add drug No Change Drug change Any change Other NC State Health Plan project results: Educational services provided % of Patients receiving DIABETES HTN CARDIO ALL PTS Medication Compliance Self monitoring device Disease Self-care 8

12 NC State Health Plan project results Satisfaction with RPh services I am satisfied with...time spent by RPh evaluating my meds. the eval of meds by my RPh... the quality of info provided by my RPh courteousness and respectfulness of med concerns The RPh cleared up my med problems. I am now better about taking my meds as prescribed. I have saved money on my meds. The SHP should offer this service to others Agree or strongly agree 94% 89% 89% 83% 67% 38% 38% 83% 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 patients High 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 problems detected at the time of dispensing Focus: Identify and resolve potential drug therapy problems at the time of dispensing 9

13 A model for providing DRUG PROBLEM RELATED services when dispensing DRUG Rx d Computer SCREEN ALERT RPH Problem identified, documented RPH ACTION I N T E R V E N T I O N R E S U L T O U T C O M E Outcomes Encounter Documentation: 5 Step Process 1. Reason 2. Action 3. Result 4. ECA 5. Notes Reference what medications are involved under Prescription Information section 10

14 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 patients High 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 problems detected at the time of dispensing Focus: Identify and resolve potential drug therapy problems at the time of dispensing The Asheville Project Asheville, NC* Employers: City of Asheville, Mission Health Care System Initially targeted at patients with diabetes. Expanded to asthma, hypercholesterolemia The offer to patients: Co-pay waiver for diabetes drugs and supplies Free personal glucose monitor Monthly appts with a community pharmacist Referral 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:

15 ASHEVILLE PROJECT RESULTS Figure 1. Percentage of Lab Values in Optimal Range Over Time Percentage of Lab Values in Optimal Range Baseline 1st Followup 2nd Followup 3rd Followup 4th Followup 5th Followup 6th Followup 7th Followup A1C LDL-C HDL-C Asheville Project: Direct Medical Costs Over Time $8,000 Mean Cost / Patient / Year $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 Other Rx Baseline Diabetes Rx Med services Follow-up Year Cranor CW, Bunting BA, Christensen DB. Long-term Outcomes of the Asheville Diabetes Pharmacist Care Project. JAPhA. 2003; 43:

16 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 City of Asheville Medical Costs $0 $6,127 $3,554 $5,021 $4,535 $3,902 $4,651 $7,248 58% % savings based on actual 2001 costs vs. expected 2001 costs (1996 costs + annual CPI medical care inflation figures) Source. J. Miall, Director of Risk Management, City of Asheville Expansion of the Asheville model: Patient Self- Management Program sm First year results* Diabetes Care Measure A1c Flu Shot Eye Exam Foot Exam Systolic BP Lipids (LDL-C) Total mean H.C Costs satisfaction with diabetes care JAPhA 2005; 45:130. Baseline % 46% 38% mg/dl 57% Followup (6mo-1yr) % 82% 80% mg/dl ( avg.: $918 lower than projected) 87% 13

17 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 2 nd or 3 rd Quarter of 2006 Data to determine actual health outcomes will not be available until mid to late

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19 IMPACT of MTMS interventions on UTILIZATION and COSTS RESULT of PHARM CARE INTERVENTION DRUG THERAPY APPROPRIATE for DISEASE STATE? PATIENT BEHAVIOR APPROPRIATE? DISEASE PREVENTED? DISEASE CONTROLLED? MEDICAL CARE UTILIZATION COST How to evaluate the impact of MTM Eligible population Target 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; intervention rate per patient with PDTP Drug therapy change rate per patient with R.Ph. intervention; change rate per PDTP 16

20 Measures of impact of pharmacist services Eligible population Target patients at risk Potential drug therapy problems Patients with ACTUAL drug therapy problem Patients with ACTUAL drug Patients therapy with problem drug therapy problem RESOLVED Economic: Rx: #, $$ Rx PMPM Physician: # visits, $$ PMPM Hospital, ED: # admits, LOS, $ PMPM Clinical Change in disease status e.g., b.p, HgA1c, lipids (HDL,LDL) FEV 1 IMPACT ECONOMIC CLINICAL HUMANISTIC 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 and barriers to providing MTM services Adequate compensation RPh professional orientation, willingness Owner-manager attitudes & support Working environment Opportunity to provide services: number of eligible patients Training, credentialing 17

21 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 evaluated Barriers and opportunities, incentives and disincentives 18

22 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

23 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

24 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