MTM – More than Myths ASAP January 2009 Objectives Obtain a better understanding of a functional face to face medication therapy management MTM program delivered through local by xep27182

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									MTM – More than Myths
        ASAP
    January 2009
Objectives
 Obtain a better understanding of a functional,
 face-to-face medication therapy management
 (MTM) program delivered through local
 pharmacists
 Explore various methods to capture pharmacists'
 services for billing and how they may (or may
 not) interface with their pharmacy management
 systems to date
 Understand the benefits and ROI of a face-to-face
 MTM service for multiple types of payors in the
 marketplace and why this area of pharmacy
 practice is growing exponentially
First Things First…
First Things First…

                      1/15/2009
                      5:00 a.m.
                      -17 F
                       -45   WC
Where are we going?
 Definition and Evolution
 Landscape
 Future
MTM Background
 Concept of Medication Therapy
 Management (MTM) services is not
 new
  Pharmaceutical  Care
  Cognitive Services

  Pharmacist Services

 Medicare Part D introduced term,
 “MTM”
What is MTM?
 As defined within the Medicare
 Modernization Act of 2003 (MMA):
  Services   designed to:
    Enhance enrollee understanding
    Increase enrollee adherence
    Detect adverse drug events, and patterns of
    overuse and underuse of prescription
    medications
MTM Payors
 Medicare Part D plan sponsors
              Drug Plans (PDPs)
  Prescription

  Medicare Advantage Prescription Drug
   Plans (MA-PDs)
 Employer groups
 State Medicaid/Other State Programs
 Pharmaceutical Manufacturers
 Patients
Who should receive MTM?
 TOTAL population (everybody is eligible)
    Proactive Approach
    Decreases the PMPM and spreads the cost over
     the entire population
    Targeted at ALL utilizers of the pharmacy
     benefit – anyone who takes prescriptions
 SELECTIVE population (criteria-based)
    Reactive Approach
    Targets high dollar/more critically ill
    Leaves gaps in care – a patient has to get “bad”
     before they get managed appropriately
MTM Landscape
 So what does MTM look like in
 Medicare?
  Wide   variability
MTM Models
 Centralized MTM
  Letter-basedMTM
  Phone-based MTM
    Pharmacists, nurses, case managers, others
 Decentralized MTM
  Face-to-face   services
    Pharmacists
Exploratory Research on
Medication Therapy Management
(MTM) – Final Report
Abt Associates Inc on behalf of CMS

  2007-2008
   Reviewed  59 publications
   Interviewed 60 individuals (representing
    46 organizations)
   Conducted 4 in-depth Case Studies
Operational      Program A                Program B                   Program C               Program D
Features         (Medicaid)               (PDP and MA-PD)             (Multi-state            National MTM
                                                                      MA Plan)                Vendor
Eligibility      4+ Rx                    9+ Rx (12 in ’06)           2+ Rx from list         Varies by
Criteria         2+ Chronic Dx            5+ Chronic Dx               of 6                    client
                 Not elig for Part        >$4K drug spend             medications             Most make
                 D                                                    2+ Chronic Dx           every plan
                 Not in a LTC                                         from list of 10         member
                                                                      CVD conditions          eligible
                                                                      >$4K drug
                                                                      spend
Enrollment       Referral by              Invitation Letter           Invitation              Automatic
Mechanism        pharmacist or            (Opt In)                    Letter with             Enrollment
                 physician                                            telephone               (No Opt In or
                 (Opt In)                                             follow-up               Opt Out)
                                                                      (Opt In)                (services can
                                                                                              be declined
                                                                                              based on type)
MTM              Face-to-face             Mailed MTM       Telephone                          Face-to-Face
Service                                   recommendations                                     (if not
Delivery                                  (pts and PCPs)                                      possible,
Mode                                      Referral to case                                    telephone)
                                          managers
 Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
 – Final Report, July 8, 2008
  Exploratory Research on
  Medication Therapy Management
      Program A
         In  the first year of the program, 34
            pharmacists provided MTM services for
            259 patients for a total of 431 visits
                 3 DTP per patient average
                 77% of patients with diabetes achieved A1c
                 benchmark goal< 8




Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
– Final Report, July 8, 2008
  Exploratory Research on
  Medication Therapy Management
      Program B
           Physician Satisfaction and Compliance with
            Recommendations
                 25% response rate
                       80% agreed with recommendations and stated they
                        would comply
                       82% of responding PCPs agreed the MTM program had
                        value for patients
           Patient Satisfaction
                 40% response rate
                       Each year, 80% who responded think MTM
                        recommendations were helpful
                       98% reported they feel better or the same

Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
– Final Report, July 8, 2008
  Exploratory Research on
  Medication Therapy Management
      Program C
           Patient Satisfaction
                 44% response rate
                 8 questions (5= Strongly Agree; 1=Strongly Disagree)
                 Average score of all 8 questions was 4.3
                 All questions answers > 4
                 Well received my patients
           Change in Lipid Control Following MTM patients:
                 MTM Patients: 62% were at goal for lipid control and 73%
                 after
                 Non-MTM patients (declined): 62% at baseline, 67% after
                 Non-Part D Controls: 67% baseline with 69% after



Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
– Final Report, July 8, 2008
  Exploratory Research on
  Medication Therapy Management
      Program D
         Florida             QIO Findings
                 Medication Adherence >80%
                       Baseline 38% and 45% post
                 A1C less than 9
                       Baseline 20% and 74% post
                 Total Cholesterol <200
                       Baseline 14% and 62% post
                 Average Total Health Care Costs                                       (7-8 months)
                       Baseline $3,167 and $3,452 post

Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
– Final Report, July 8, 2008
  Exploratory Research on
  Medication Therapy Management
      Program D
         MTM            Trends
                 3.2 interventions per patient per year
                 Avg ECA per claim
                       2000-2002: <$50
                       2006: $450
                 45% of CMRs led to other interventions
                       90% prescriber acceptance
                       $735 ROI per CMR that resulted in additional
                        interventions
                       10% of interventions may have prevented an ER
                        visit or worse
Abt Associates Inc on behalf of CMS, Exploratory Research on Medication Therapy Management (MTM)
– Final Report, July 8, 2008
Pharmacy MTM Programs
 Mirixa (Community CCRx)
 Outcomes Pharmaceutical
 Health Care® (Outcomes®)
 Humana
Mirixa
  MemberHealth
  Targeted Members
   4  or more disease states (must have at
     least 1 “targeted disease state”)
    10 or more medications

    $4,000+ in drug costs




www.mirixa.com
Mirixa
  Covered Services
    One medication therapy review/year
    Other services
          Formulary Review
          Welcome to CCRx Review
  Billing
    www.mirixa.com




www.mirixa.com
Mirixa
  Network Requirements
    Contract

    Pharmacist   training available but not
      required




www.mirixa.com
Mirixa




www.mirixa.com
Humana
  Tiered approach with letters, call
  center, de-centralized pharmacy
  MTM services
  Targeted members
   2  or more disease states
    8 or more chronic, systemic Part D
     medications
    $4,000+ in drug costs


www.humana.com
Humana
  Covered Services
           medication therapy review
    Initial

    Follow-up, as necessary

  Billing
    Real-timethrough NCPDP 5.1
    Uses MTM CPT codes and PPS codes




www.humana.com
Humana
  Network requirements
      Existing dispensing contract with Humana
      Private/semi-private consultation room
      Attest to strong understanding of the following
       guidelines:
         JNC 7
         NCQA Criteria for Potentially Inappropriate
         Medications Used in Older Adults
         ADA
         NCEP
      Must have email capabilities to communicate
       with Humana
      Specific NCPDP 5.1 billing capabilities

www.humana.com
Humana




www.humana.com
Outcomes
  Medicare Part D Plans
    PDP

    MA-PD

  Employer Groups
  Pharmaceutical Manufacturers
  Patients



www.getoutcomes.com
Outcomes
  Covered Services
      Comprehensive Medication Review
      Prescriber Consultation
          Cost Efficacy Management
          Drug Therapy Problem Resolution
      Patient Compliance Consultation
      Patient Education & Monitoring
  Billing
      www.getoutcomes.com
          Reason-Action-Result Codes
          Notes
          ECA
          Prescription Information
www.getoutcomes.com
Outcomes
  Estimated Cost Avoidance Model (ROI)
  Pharmacist assigns a severity rating to
  each MTM claim:
      Level   1   –   Improved Quality of Care
      Level   2   –   Drug Product Costs
      Level   3   –   Additional Physician Visit
      Level   4   –   Additional Prescription Order
      Level   5   –   Emergency Room Visit
      Level   6   –   Hospital Admission
      Level   7   –   Life Threatening

www.getoutcomes.com
Outcomes
  Encounter Program
      “Pull” program (pharmacist-initiated)
  Targeted Intervention Program (TIP®)
      “Push” program (plan-initiated)
      Retro-DUR analysis
      Distributed to all dispensing pharmacies
      Targeted Interventions
          Examples:
               HEDIS/HCQA measures
               Formulary Management


www.getoutcomes.com
Outcomes
  MTM Network Agreement
      Single Location Pharmacy (sign-up online)
      Multiple Location Pharmacy
      Alternative Location (sign-up online)
          Outpatient Clinic
          Consultant Pharmacist/Independent Contractor
  Pharmacist Training
      8 modules (available online)
          1 hour
          No cost
  Identify Eligible Patients
www.getoutcomes.com
Outcomes




www.getoutcomes.com
But WAIT! Change is coming…
                      CMS 2010 Call Letter
                         Changes in Eligibility
                            8 meds or <
                            3 diseases or <
                            $3K Spend
                            Must target at least
                            quarterly
                         OPT OUT ONLY
                         Services
                            Low Touch Only (i.e.
                            Letters)



www.getoutcomes.com
But WAIT! Change is coming…
                      CMS 2010 Call Letter
                         Services Changes
                            CMR offered
                            Must be interactive
                            Quarterly Targeted
                            Interventions
                         Extensive Reporting
                          changes




www.getoutcomes.com
Pharmacy’s Operational Challenge
            Prescription Claims Processing Standards

 Pharmacy A                                                        Payor A
                           S
                           O            N
 Pharmacy B                F            C                          Payor B
                                                    P
                           T
                                        P           B
                           W
                                                    M
 Pharmacy C                A            D                          Payor C
                           R
                           E            P
 Pharmacy D                                                        Payor D


 eg, QS1, HCC, ScriptPro, Walgreens’ Own, etc



               eg, Caremark, Express Scripts, WHI, Member Health
Pharmacy’s Operational Challenge
                      MTM Claims Processing
                    (There Is No Operational Standard)

 Pharmacy A                     Platform A                         Payor A


 Pharmacy B                     Platform B                         Payor B


 Pharmacy C                     Platform C                         Payor C


 Pharmacy D                     Platform D                         Payor D



                 eg, Outcomes Pharmaceutical Health Care web
              platform, Mirixa web platform, CPT Codes via NCPDP
                            5.1 for Humana, faxes, etc
An Illustrated Example of
Inefficiency for the Providers




 www.getoutcomes.com
     Outcomes Client Base
                                                                                King County (Seattle)
                                                                                City of Ames
                                                                                CarePro Health Services
Alameda Complete Care
(2008)                                                                          Blue Ridge Paper Products

CareFirst BCBS (2008)                                                           Pharmacist Mutual
                                                  Florida Medicaid Quality
ChecKmeds NC                                                                    Outcomes Pharmaceutical Health Care
                            CareFirst BCBS        Related Events (QRE)
Freedom Health (2008)                             Program                       Alameda Alliance for Health
                            ChecKmeds NC
Health Plan of San Mateo                                                                                       Seroquel®
                            HealthSpring (2008)
John Deere Health Care                                                                                         Actonel®
                            Others pending…
Partnership Healthplan                            Medicaid                   Employers                         Atrovent HFA®
of California                                                                                                  /Spiriva®
Senior Whole Health
                           Medicare                                                                            Pleio GoodStart for
Sentara/Optima Health                                                                               Pharm      Diovan®
                             PDP
UAHC of TN (2008)                                                                                    Mfr
                                                                                                                           Personal
Others pending…                                                                                                            Pharmacist™
                                                                                                                           Program


         Medicare
                                                                                                              Consumers
          MA-PD


                                        Local independent, chain,
                                      consultant, and health system
                                           pharmacy providers
Electronic Charting Platform




 Dashboard
Electronic Charting Platform




 Claim Submission
Electronic Charting Platform




 Encounter Notes & ECA Rationale
Electronic Charting Platform




 Prescription Information
Electronic Charting Platform



                 Electronic
                 interfaces with
                 pharmacy
                 management
                 software system
                 would improve
                 efficiencies




 Drug Database
Electronic Charting Platform

                Electronic
                interfaces with
                pharmacy
                management
                software system
                would improve
                efficiencies




 TIP Queue
Electronic Charting Platform



                Electronic
                interfaces with
                pharmacy
                management
                software system
                would improve
                efficiencies




 Patient List
Electronic Charting Platform




 Electronic Patient Chart
Electronic Charting Platform




 MTM Profile
Electronic Charting Platform


                   Electronic
                   interfaces with
                   pharmacy
                   management
                   software system
                   would improve
                   efficiencies




 MTM Profile
Electronic Charting Platform




 Printed MTM Profile
Pharmacy’s Operational Challenge
                      MTM Claims Processing
                    (There Is No Operational Standard)

 Pharmacy A                     Platform A                         Payor A


 Pharmacy B                     Platform B                         Payor B


 Pharmacy C                     Platform C                         Payor C


 Pharmacy D                     Platform D                         Payor D



                 eg, Outcomes Pharmaceutical Health Care web
              platform, Mirixa web platform, CPT Codes via NCPDP
                            5.1 for Humana, faxes, etc
Standardization
 MTM “Communication”
  Patient Eligibility
  Patient Information

  Interventions

  Billing

 Some coalescing likely to occur,
 although may not be just ONE
 standard
Standardization
 Current efforts:
  Pharmacy   Services Technical Advisory
   Coalition (PSTAC)
  National Council for Prescription Drug
   Programs (NCPDP)
Standardization
 Pharmacy Management Systems
  Keep  dialogue going – web services can
   be created to integrate now – even if it
   is with multiple platforms
  MTM opportunities are not decreasing –
   they are INCREASING! Take this IT
   request and move it off the back burner
Q&A


           Patty Kumbera, Co-founder and COO
      Jessica Frank, Director of Clinical Services
          Outcomes Pharmaceutical Health Care
                        601 E Locust, Suite 200
                    Des Moines, IA 50309-1946
                            voice 515.237.0001
                               fax 515.237.0002
                         www.getoutcomes.com
Post-Test Q&A
  As defined within the Medicare
  Modernization Act of 2003 (MMA)
  MTM services are to be designed to
  do which of the following?
 A.   Enhance enrollee understanding
 B.   Increase enrollee adherence
 C.   Detect adverse drug events, and
      patterns of overuse and underuse of
      prescription medications
 D.   All of the above
Post-Test Q&A
  Which of the following “Payors”
  have compensated pharmacists for
  MTM:
 A.   Medicare Part D PDPs and MA-PDs
 B.   Medicaid programs
 C.   Employers
 D.   All of the above
Post-Test Q&A
  The MTM landscape within Medicare
  and all market areas contains wide
  variability.
 A.   True
 B.   False
Q&A


           Patty Kumbera, Co-founder and COO
      Jessica Frank, Director of Clinical Services
          Outcomes Pharmaceutical Health Care
                        601 E Locust, Suite 200
                    Des Moines, IA 50309-1946
                            voice 515.237.0001
                               fax 515.237.0002
                         www.getoutcomes.com

								
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