Download 2016 M TM Trends r epor T

2016 MTM Trends Report
The 4th annual MTM Trends Report
compiles metrics, case studies,
stories and more to showcase the
current state of Medication Therapy
Management and emerging trends.
Within this report, we look at
community pharmacies’
engagement in MTM,
review exciting new
developments impacting
both payors and providers
and share insights
into the future of MTM.
04
Where is
MTM Today?
10
Top MTM Centers
+ Top Chains
14
Look at how pharmacies
are engaging in MTM
like never before
View the best of the best
in the OutcomesMTM
Personal Pharmacist™
Network
See how MTM services
made a difference for
three patients
> Power of the Network
> Network Performance Maps
2016 MTM Trends Report
MTM
in Action
MTM in 2015
Review key
developments
and MTM
milestones
> 2015 MTM Timeline
> National MTM Advisory Board
20
28
See stats on Medicare
MTM programs and how
CMS Star Rating changes
are affecting MTM
Look ahead to a
changing healthcare
landscape and the
evolution of MTM
> Medicare MTM Program Facts
>CMS Star Ratings
>CMR Completion Rates
>Blue Shield of California
Case Study
>Adherence
> Future of Healthcare
Key Facts
CMS,
MTM + CMRs
Where is
MTM Going?
New MTM
Models +
Services
Consider new ways
healthcare payors
are using MTM to
improve outcomes
> Enhanced MTM Model Test
> Blue Cross & Blue Shield of
Rhode Island Case Study
> New MTM Services:
MedSync + MedRec
40
The ROI
of MTM
Review measures
of success for MTM
> Passport Health Plan
Case Study
Where is
MTM
Today?
The end of 2015 marked the close of the first decade of Medicare Part D. The launch of the
Part D benefit was a milestone for Medication Therapy Management (MTM) as it marked
the first time Medicare recognized MTM as a payable service. In the ensuing decade, MTM
has grown and evolved significantly. Government regulations and performance ratings
have stoked innovation, particularly in the last five years. More innovation will follow with
new approaches, better technology, wider adoption of MTM (by both pharmacists and
patients) and the Enhanced MTM Model test for PDP plans.
Over the last 17 years, OutcomesMTM®, now a Cardinal Health company, has catalyzed the evolution of MTM. From the first
pioneering pharmacists to the engaged network of thousands of local pharmacists today, OutcomesMTM has provided support
and ever-increasing opportunities to demonstrate value for healthcare payors. Pharmacies across the country have adopted MTM,
delivering services for millions of patients that not only impact facts, figures and ratings—but also lives. From educating on a
new prescription to resolving an adverse drug reaction that helps a husband return to daily walks with his wife,
pharmacist-delivered MTM services improve quality of life as well as quality of care.
Why is MTM activity increasing?
1. The foundation has been developing for many years. Local pharmacists have never been more
prepared to successfully and consistently deliver MTM services than they are today.
2. Pharmacies, including large pharmacy chains, are investing resources in MTM at unprecedented levels.
This includes investments in people, processes and technology to sustainably incorporate
MTM into daily practices.
3. Demand is at an all-time high. Medicare Star Ratings related to Comprehensive Medication Reviews
and medication use are driving plan sponsors to seek new strategies for reaching members and
influencing behavior.
Local pharmacies have made great strides in the delivery
of MTM over the last 10 years. It is a story about action
leading to results—one that is worth telling again and
again—to every healthcare stakeholder.
Brand Newland, VP of Business Development
OutcomesMTM
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OutcomesMTM® Trends Report | 2016
MTM Today
POWER OF THE NETWORK
How active are
local pharmacists in
MTM today?
Nearly 7,000 new pharmacies
participated in OutcomesMTM
programs in 2015.
137, 870
Last year, more than 34,000 pharmacies submitted an
MTM claim—almost 7,000 of them new to MTM. This
increase greatly enhanced the network’s capability to
respond to the needs of millions of MTM-eligible patients.
MTM services
The number of MTM service
claims increased by 90% over 2014.
Just shy of 50,000 pharmacists and 8,800 technicians
worked on MTM opportunities in 2015. Although MTM is
most often associated with CMRs, these 2.4 million MTM
encounters also represent local pharmacists assisting
patients outside CMS-required MTM programs. Every day,
MTM services benefit members of Medicare, Medicaid,
commercial and other groups.
More activity resulted in a 160%
increase in MTM service payments
to pharmacies in 2015.
Today, more than half of U.S. pharmacies are active
in OutcomesMTM programs, earning revenue for
their clinical services while helping healthcare
payors reach their goals.
106,000
MTM claims
for patients who could not
receive MTM services at
their local pharmacies.
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OutcomesMTM® Trends Report | 2016
72
In addition to the
2.4 million MTM service
claims submitted by
network pharmacists,
remote telephonic teams
contributed an additional
Average calls per day
to the OutcomesMTM
Provider Resources
Help Desk
333
per pharmacist-identified
cost-savings intervention:
helped patients
avoid unnecessary
healthcare utilization
(doctor appointments,
hospitalizations, ER visits and
life-threatening events)
of Successfully
resolved
Prescriber-level
interventions
were validated
in prescription
claims data
$656.39
2016 | OutcomesMTM® Trends Report
7
MTM Today
Network Performance
2015 comprehensive medication reviews
This map details a state-by-state comparison of Comprehensive Medication Review (CMR) activity.
2015 MTM SERVICE ACTIVITY
This map provides a state-by-state comparison of overall MTM service activity, including all service types: Comprehensive
Medication Reviews (CMRs), prescriber consultations and patient consultations for adherence or education.
CMRs
10K – 70K
5K – 10K
PEAK DAY
OF CMRs
1K – 5K
1 – 1K
1,731
Service Activity
100K – 535K
50K - 100K
10K – 50K
5K – 10K
1 – 5K
70%
2015 drug therapy problems
This map displays a state-by-state comparison of MTM services related to
drug therapy problems (DTPs). This subset includes prescriber consultations
and patient adherence consultations.
PEAK DAY
OF MTM ACTIVITY
11,586
MTM Service
Claims
62%
of MTM CLAIMS
END in A
SUCCESSFUL
RESULT
of drug therapy
problems identified
WITH a CMR were
resolved
Drug Therapy Problems
50K – 205K
10K – 50K
5K – 10K
1K – 5K
1 – 1K
*Maps represent MTM activity based on MTM service claims from 2015. All data maps are based upon patient’s state of residence.
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OutcomesMTM® Trends Report | 2016
2016 | OutcomesMTM® Trends Report
9
MTM Today
State/Territory Winners
NE
W
NORTHEAST
WEST
TOP MTM
Each year, OutcomesMTM recognizes pharmacies and pharmacy
chain organizations with exceptional performance in delivering
MTM services. Top MTM Center and Top Chain awards are based on
the organization’s overall effectiveness in delivering CMRs and
resolving drug therapy problems through TIPs. Being named one of
the best in the industry’s largest, most engaged provider network is
a testament to these organizations’ outstanding work.
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OutcomesMTM® Trends Report | 2016
FRED MEYER PHARMACY 70100224
FAIRBANKS
AK
KMART PHARMACY 3923NOGALES
AZ
RALPHS PHARMACY 70300756PLACENTIA
CA
GOOD DAY PHARMACYEATON
CO
MAUI CLINIC PHARMACY
KAHULUI
HI
KMART PHARMACY 3298
BOISE
ID
Walmart 3259
MISSOULA
MT
FARMINGTONNM
Walmart 3428
SMITHS PHARMACY 70600390
WENDOVERNV
FRED MEYER PHARMACY 70100227NEWPORTOR
CECILS PHARMACY
LEHI
UT
RITE AID PHARMACY 05275
UNIVERSITY PLACE
WA
GILLETTE
WY
Walmart 1485
Walmart 2232
BRANFORD
CT
GIANT PHARMACY 2376
WASHINGTONDC
WALGREEN DRUG STORE 11006
WILMINGTONDE
WALGREEN DRUG STORE 06349DORCHESTER
MA
WALGREEN DRUG STORE 06007
BROOKLYN
MD
HANNAFORD FOOD AND DRUG 8347
AUBURN
ME
HANNAFORD FOOD AND DRUG 8178
MANCHESTERNH
FENNY PHARMACY
JERSEY CITYNJ
MEDICINE SHOPPE 1454
CAMDENNY
SHEEHANS PHARMACYPLAINSPA
RITE AID PHARMACY 10256EAST PROVIDENCERI
Kinney Drugs #56
BRADFORD
VT
CENTERS
C
CENTRAL
HY-VEE DRUGSTORE 7020
CEDAR RAPIDS
IA
Walmart 1668
GURNEE
IL
Walmart 1341EVANSVILLE
IN
SAMS CLUB PHARMACY 8254
WICHITA
KS
MEIJER PHARMACY 072
BELLEVILLE
MI
SHOPKO PHARMACY #603PRINCETON
MN
WEBBER PHARMACY
MEXICO
MO
MEDICINE SHOPPE 1169
FARGOND
SHOPKO PHARMACY #044OMAHANE
MARCS AURORA
AURORAOH
KMART PHARMACY 7306SIOUX FALLSSD
Walmart 958PLATTEVILLE
WI
SE
SOUTHEAST
RITE AID PHARMACY 07005
CULLMAN
AL
BROOKSHIRE PHARMACY 081
MAGNOLIA
AR
RON’S PHARMACY
FORT LAUDERDALE
FL
FREDS PHARMACY 1479DUBLIN
GA
RITE AID PHARMACY 01540
WHITESBURG
KY
Walmart 3745
MONROE
LA
FREDS PHARMACY 1091PEARL
MS
RITE AID PHARMACY 11403DURHAMNC
MED-WORLD PHARMACYSAPULPAOK
FARMACIA REY 5SAN JUANPR
PUBLIX PHARMACY 0543DUNCANSC
BURDEN DRUG CENTER #3581
JAMESTOWN
TN
HOMETOWN DRUGENNIS
TX
RICHLANDS PHARMACYRICHLANDS
VA
Walmart 2576
CROSS LANES
WV
MTM Today
TOP PHARMACY CHAINS
Large Chain Category
Medium Chain Category
Regional Chain Category
(Chains with 900+ locations)
(Chains with 200-899 locations)
(Chains with <200 locations)
“In the heart of every practicing pharmacist is the desire to
provide MTM. Rekindling that flame has ignited our success.
MTM performance is directly tied to team engagement.
This starts at the very top with our organization’s leadership
and goes all the way to technicians at our stores. We set
goals and expectations for MTM performance and regularly
communicate progress. It is important to not only coach
those who are underperforming but to also celebrate and
share the successes of those who are doing well.”
- Jim Kirby, PharmD, BCPS, CDE, Clinical Strategy and Programs
RUNNER-UP
“Our local pharmacists’ training and engagement in
the MTM program has helped us succeed with MTM
and provide the individualized care our patients
need. MTM gives us the opportunity to care for
them beyond dispensing their medications, and
we see direct value in our patients’ satisfaction. Our
MTM achievements mean our patients succeed in
improving their health—the ultimate award for us.”
- John DeJames, Manager of Clinical Programs
“Medication therapy management is more than just
the pharmacist acting as the bridge between the
patient and the insurance company. It gives us the
opportunity to educate the patient, listen to their
concerns, and work together to increase their overall
health. Being recognized as the Top Regional Chain
two years in row is a tremendous honor and speaks
volumes to the commitment that our pharmacists
have towards our patients and their needs.”
MOST IMPROVED
“We collaborated with OutcomesMTM to improve patient
outcomes as well as help transition to the new ACA star ratings
system at our pharmacies. This increased collaboration led to
a dramatic increase of completed TIPs, CMRs and pharmacy
revenue. We feel MTM is an important part of patient care, and
we are honored to be recognized for our efforts.”
- Dave Chism, RPh., MBA, Director of Pharmacy Services
MOST INNOVATIVE
- Tom Roth, Director of Pharmacy Operations
RUNNER-UP
RUNNER-UP
“We fostered a culture change that valued and measured MTM
services as equal to prescriptions in serving our guests and supported
it with goals, resources and training to enable our pharmacists and
technicians to practice at the top of their respective licenses. Data
analytics, actionable reporting and easy-to-execute interventions
resulted in phenomenal execution that delivered results well ahead of
our goals–with meaningful and measurable impact on patient care. “
- Victoria Losinski, PharmD, PhD, Senior Professional Services Manager
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OutcomesMTM® Trends Report | 2016
2016 | OutcomesMTM® Trends Report
13
Resolving Adherence Barriers
Clearing Up Post Discharge Confusion
Personal Pharmacist™ Bethany Lalonde
Walmart 5424 – Eagle Point, OR
Personal Pharmacist™ Greg Baker
Sixth Street Drug Inc. – Traverse City, MI
A TIP alerted Bethany that a patient was not adherent to
her diabetes medication. When she spoke with the patient,
Bethany learned the woman had stopped taking the
medication due to side effects. She counseled her on the
importance of taking the medication to decrease the risk of
complications related to uncontrolled blood sugars, such as
kidney damage or nerve pain. She also informed the patient
about an alternative formulation that causes fewer stomach
issues while still controlling blood sugars. The patient agreed
to try the alternative medication, so Bethany contacted the
prescriber for a new prescription.
Greg learned that his patient, who had recently started a
blood thinner, was discharged from the hospital after a
readmission related to blood loss. The patient was confused
by his discharge summary and unsure if he should restart
his blood thinning medication. For this patient, continuing
the medication could lead to another hospitalization for
uncontrolled bleeding, so Greg conferred with the hospital.
After confirming the medication was discontinued, Greg
counseled the patient on why he should hold the medication.
Preventing Pregnancy Complications
Personal Pharmacist™ Tina Shook, Discount Drug Mart 16 – Willard, OH
While counseling a patient on a new medication, Tina learned the woman
was pregnant. The patient was also picking up a medication for high
blood pressure that Tina recognized as contraindicated in pregnancy due
to risk for skeletal, lung and kidney issues in a fetus. She contacted the
patient’s OB/GYN, who reported not having the medication on the list
provided by the patient. Tina educated the patient about the risks of the
blood pressure medication and sent a current list of prescriptions for the
physician to determine which therapies should be discontinued or altered
during the patient’s pregnancy.
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OutcomesMTM® Trends Report | 2016
MTM Today
MTM IN ACTION
MTM Today
MTM
2015 was a pivotal year for MTM in
many ways. Two major milestones
marked it as one of the biggest
years for MTM so far—CMS moved
CMR Completion Rate from display
to an official Star measure and
announced the measure’s cut
points for 2016 Star Ratings.
But, MTM’s moment in the spotlight didn’t stop there.
It was the topic of a Congressional hearing and inspired
a new model test that invited PDP plans to innovate in
order to improve outcomes and reduce Medicare costs.
It was also a record breaking year for OutcomesMTM.
More pharmacies participated than ever before. The
number of MTM encounters nearly doubled over 2014,
and pharmacies earned the most service fees on record.
The best part is that all these numbers reflect something
even more important—great patient care.
JAN
FEB
CMS RetirES
DTM MEASURE
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OutcomesMTM® Trends Report | 2016
Retirement of DTM Star Measure (February)
Enhanced MTM Model Test (September)
The Center for Medicare and Medicaid Innovation (CMMI) announced a new pilot to spur MTM innovation.
Part D plans in select states were invited to implement their visions for an Enhanced MTM Model. January
2017 may bring exciting new MTM opportunities to community pharmacies, as they will be an important
tool for plan sponsors to leverage.
Following new JNC-8 guidelines that expanded the preferred first-line
hypertension medications for patients with diabetes, the Centers for Medicare
and Medicaid Services (CMS) announced they would retire the Appropriate
Treatment of Hypertension in Persons with Diabetes measure for the 2017 Star
Ratings but later delayed retiring the measure until the 2018 Star Ratings.
CMR Cut Point Announcement (September)
When CMS released cut points for the 2016 Star measure, MTM Program Completion Rate for CMR,
Medicare plans rushed to improve their CMR performance late in 2015. Growing demand for completed
CMRs positions MTM providers like the OutcomesMTM Personal Pharmacist Network to satisfy health plans’
needs. OutcomesMTM expects the ripple effects of the cut points to make CMRs a top priority for many
Medicare plans in 2016.
OutcomesMTM Acquisition (July)
OutcomesMTM joined Cardinal Health—combining its industry-leading MTM
network and technology with the broad healthcare expertise of Cardinal
Health—to create state-of-the-art MTM programs. The Cardinal Health Patient
Engagement Team joined the OutcomesMTM Personal Pharmacist™ Network,
offering healthcare payors the benefits of a dual-channel model.
MTM Testimony in Congress (October)
Telehealth CMRs (September)
MTM was the focus of a Congressional subcommittee hearing titled, “Examining the Medicare Part D
Medication Therapy Management Program.” Committee members heard testimonies from multiple
stakeholders, including representatives from CMS, industry think tanks, trade organizations, health systems
and retail pharmacy. Testimonies illustrated how the CMS MTM program has shown measurable success as
well as opportunities for further improvement. OutcomesMTM was cited as an example of how expanding
MTM access for patients to community pharmacy can be a cost-effective quality strategy.
Health systems, rural clinics, retail pharmacies and other healthcare providers
contributed to significant advancements in telehealth (video conferencing).
This convenient, cost-effective technology engages patients not easily
reached by traditional methods. OutcomesMTM added “telehealth” as a
documentable delivery method for CMRs to capture the impact of the new
technology. OutcomesMTM reports this data to CMS annually, so they can
better understand the scope of telehealth and its impact on their
measurable outcomes.
MAR
MOST active
month for
OUTCOMESMTM
(250K+ MTM CLAIMS)
APR
OutcomesMTM
addS Spanish
Patient Takeaway
MAY
JUN
CMS announces
cmr completion
rate as 2016 star
measure
2015 OUTCOMESmtm
claim activity
Surpasses total
2014 activity
JUL
AUG
CARDINAL HEALTH
acquires
Outcomesmtm
CMS Announces
ENHANCED MTM
MODEL TEST
Jesse McCullough,
Director of Field Clinical Services
Rite Aid Corporation
CMS Releases
CMR CUT POINTS
SEP
OutcomesMTM Adds
TELEHEALTH CMR
TO CONNECT™
OCT
Through
personal interactions
with patients, faceto-face consultations,
and convenient
access to preventive
care services, local
pharmacists are
helping to shape the
healthcare delivery
system of tomorrow
—in partnership with
physicians, nurses,
and others healthcare
providers.”
NOV
DEC
CONGRESSional
committee hears
MTM Testimony
2016 | OutcomesMTM® Trends Report
17
MTM Today
MTM
Payors
Formed in 2010, the National MTM Advisory Board brings together
representatives from multiple stakeholder groups to build
consensus and influence policy development in the MTM industry.
The Board incorporates a diverse mix of viewpoints and experience from payors, pharmacists and physicians.
As thought leaders, members of the Board address both the short- and long-term positioning of MTM services
within the larger healthcare picture. OutcomesMTM provides administrative support for the Board.
Physicians
Payors
Representative
AultCare
Terra Wonsettler, PharmDDirector of Pharmacy
Blue Shield of CaliforniaSalina Wong, PharmDDirector, Clinical Pharmacy Programs
Blue Cross & Blue Shield of Rhode Island
Beth Hebert-Silvia
CareSource James Gartner, RPh, MBASenior Vice President, Enterprise Health Partner Services
Humana Inc.
Michael Taday, PharmD, MBADirector, Pharmacy Professional Practice & Clinical Operations
Medica Health PlanDavid Coffee, PharmD, MBA
UnitedHealthcare
Manager, Clinical Pharmacy Programs
Jeff Pohler, RPhSenior Director Medicare and Retirement
Part D MTM Measure Concepts
The Board highlighted the importance of meaningful data collection for
MTM program reporting and urged CMS to consider adopting a standard
definition of a drug therapy problem to use when reporting Element X
(topics discussed with the beneficiary during the CMR). This data, if reported
to CMS in a manner that allows comparison across plan sponsors, may
begin to provide insight into the value of the CMR service and can serve
as a starting block for performance measure development in the future.
Passionate about retaining the quality improvement intent of the Comprehensive
Medication Review (CMR), the Board has been advocating for a companion, qualityfocused measure to the new 2016 Star measure, Medication Therapy Management
Program Completion Rate for CMR, since 2012.
Providers
OutcomesMTM® Trends Report | 2016
Managing Director, Pharmacy
Prime TherapeuticsSara ManderfieldSenior Product Manager, Clinical Solutions
Part D MTM Program Reporting
Landscape in early 2016:
In the CY2017 Call Letter, CMS suspended the requirement for plan sponsors
to report Element X for the 2016 reporting period. But, they encouraged
plans to begin developing the capacity to collect and report drug therapy
problems using a standard framework and common terminology. CMS
plans to propose new data elements for Part D Reporting Requirements as
early as 2017 to capture drug therapy problems using standard categories
and definitions.
Title
Priority HealthErica Clark, PharmDDirector, Clinical Pharmacy Programs
Advocacy in 2015
18
MTM
Providers
In 2015, the Board made development of CMR value concepts a top priority
and presented three concepts to the Pharmacy Quality Alliance (PQA) and
CMS for consideration as additional quality measures for future years.
> Average number of prescriber recommendations per CMR
> Average number of drug therapy changes per CMR
> Percentage of prescriber recommendations made during
a CMR that resulted in a drug therapy change
Landscape in early 2016:
The 2017 Enhanced MTM Model test for PDP plan sponsors includes
proposed monitoring measures :
> Percentage of Targeted Beneficiaries with at least One Medication Therapy Issue
> Percentage of MTM Recommendations that were Implemented
Apple Discount Drugs Geoff Twigg, PharmD, BCACP, CDE
Clinical Pharmacist
Cardinal Health
Brad Tice, PharmD, MBA, FAPhAProduct Leader - Medication Therapy Management
Discount Drug Mart Michele Golob, PharmD, BCACP, CDENE NE Ohio Regional Pharmacy Supervisor/MTM Clinical Specialist
New Albertsons Inc.
Brian Hille, RPh
Target
Victoria Losinski, PharmD, PhDSenior Professional Services Manager
The Kroger Co.
Jim Kirby, PharmD, BCPS, CDE
Clinical Services Coordinator
Thrifty White Pharmacy
Timothy L. Weippert, RPh
Chief Operating Officer
Walgreens Co.
Catherine MacphersonDivisional Vice President, Enterprise Adherence
Vice President, Patient and Specialty Care
Physicians
Predictive Health, LLC Joel Brill, MD, AGAF, CHCQM Physician, OutcomesMTM Medical Director;
Chief Medical Officer, Predictive Health, LLC
2016 | OutcomesMTM® Trends Report
19
MTM Today
MEDICARE MTM
CMS2015MTM
Medicare Part D Medication Therapy Management (MTM) Programs Facts from the Centers for Medicare and Medicaid Services (CMS)
Approximately 56% of MTM
programs target beneficiaries
who have filled at least eight
covered Part D drugs.
17.1% of programs allow any Part D drug to qualify for this
requirement. The remaining programs require Part D drugs for
chronic conditions (72.1%) or specific Part D drug classes (10.8%).
Medicare MTM
programs offering
face-to-face
consultations
57.5%
15.7%
Almost 24% of
MTM programs use
expanded eligibility
requirements
Because MTM services help optimize medication use, they impact
several Medicare Star Ratings. Each year, CMS releases a Call
Letter outlining measure changes. The CY17 letter included
several updates related to MTM.
Major changes
to Star Ratings
up from 19% in 2014
73% utilize an
MTM vendor
MTM Program Completion Rate for CMR
will be included in the Drug Plan Quality
Improvement measure for the 2017 Star
Ratings, asserting the importance of
year-over-year improvement.
The High Risk Medication (HRM) measure remains a
Star measure for 2017 Star Ratings but will move to a display measure for 2018.
measures to watch
Several up-and-coming measures can be impacted by MTM services.
New Star measure for 2018 Star Ratings:
> Medication Reconciliation Post Discharge (Part C)
Over 66% of Medicare MTM
programs use their MTM vendor’s
in-house pharmacists to deliver the
CMR; 28% use their MTM vendor’s
local pharmacists.
Medicare MTM
programs offering
telehealth
consultations
2015
CMS Star Ratings
2015
About CMS Medicare Star Ratings
The Centers for Medicare and
Medicaid Services (CMS)
established Star Ratings to monitor
the quality of Medicare Part D
plans. Based on their annual
ratings, health plans earn rewards,
such as quality bonus payments
or marketing advantages, or face
consequences, such as potential
loss of patients. Star Ratings serve
as a grading system on a 1-5 star
scale. Each plan is rated on a variety
of measures that examine all
parts of a Part D plan.
For more information on CMS Star
Ratings, visit medicare.gov. View the
final CMS Call Letter at https://www.
cms.gov/Medicare/Health-Plans/
MedicareAdvtgSpecRateStats/Downloads/
Announcement2017.pdf
Measures that will remain on the display page for 2 years
and may become future Star measures:
> Statin Therapy for Patients with Cardiovascular Disease (Part C) (Likely to be a 2019 Star measure)
> Statin Use in Persons with Diabetes (SUPD) (Part D) (Likely to be a 2019 Star measure)
> Medication Management for People with Asthma (Part C)
> Asthma Medication Ratio (Part C)
Centers for Medicare and Medicaid Services (CMS). 2015 Medicare Part D Medication Therapy Management (MTM) Programs Fact Sheet.
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/CY2015-MTM-Fact-Sheet.pdf. Accessed Apr. 8, 2016.
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2016 | OutcomesMTM® Trends Report
21
MTM Today
MEDICARE MTM
The bar is set for CMR Completion Rates
2016 CMR Cut Points
Part D plans’ 2016 CMR completion rates will receive a 2018 Star Rating for
measure, D15 - MTM Program Completion Rate for CMR. In preparation for
the move from display to official Star measure, CMS released the
following cut points in September of 2015. The thresholds set a
high standard, affirming the importance of the CMR service.
MAPD PDP
1 Star: 2 Star: 3 Star: 4 Star: 5 Star: <13.6%
≥13.6% to <36.2%
≥36.2% to <48.6%
≥48.6% to <76.0%
≥76.0%
1 Star: 2 Star: 3 Star: 4 Star: 5 Star: <8.5%
≥8.5% to <16.6%
≥16.6% to <27.2%
≥27.2% to <36.7%
≥36.7%
2016 National
Average MAPD
2016 National
Average PDP
30.9%
15.4%
Centers for Medicare and Medicaid Services. “Medicare 2016 Part C & D Star Rating Technical Notes Draft.” Sept. 30, 2015.
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2016-Technical-Notes-Preview-2-v2015_09_02.pdf
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OutcomesMTM® Trends Report | 2016
After the cut points were announced, completing CMRs shifted from one of several MTM goals to
the top priority for many Medicare plans. With only a few months left in the year, plans working with
OutcomesMTM targeted a wide range of CMR completion rates for 2015.
With CMRs at the forefront, OutcomesMTM began offering a CMR Completion Rate Guarantee to help
plan sponsors achieve their specific goals. As plans finalize their 2016 programs, CMR completion rate
goals remain diverse.
Range of CMR
Completion Rate
Guarantee targets
that Medicare
plans have
explored for
CY2016
20-85%
As MTM stakeholders continue to observe the effects of the cut points, three themes stand out:
1. Not every plan sponsor will seek
the highest CMR completion rate
possible. Each plan must evaluate
ROI to determine how it will invest
in CMR completion rate versus
other quality initiatives.
2. To perform at the highest
levels, plan sponsors will likely
need multiple delivery channels:
face-to-face, telephonic and even
telehealth. They will also find ways to
reach members not accessible through
traditional channels, such as those in
long term care facilities.
3. The need for quality-based
companion measures to the CMR
completion rate measure is acute.
In a race to high volumes of CMRs, the
addition of quality metrics will help
ensure the CMR remains valuable to
beneficiaries and achieves CMS’ goals
of better outcomes and reduced
healthcare spending.
CMS Definition of a CMR: An interactive person-to-person or telehealth medication review and consultation conducted in
real-time between the patient and/or other authorized individual, such as prescriber or caregiver, and the pharmacist or other
qualified provider and is designed to improve patients’ knowledge of their prescriptions, over-the-counter (OTC) medications,
herbal therapies and dietary supplements, identify and address problems or concerns that patients may have, and empower
patients to self manage their medications and their health conditions.
2015 Medicare Part D Medication Therapy Management (MTM) Programs Fact Sheet
2016 | OutcomesMTM® Trends Report
23
MTM Today
MTM SPOTLIGHT
Member
Satisfaction
Blue Shield of California Medicare
PROGRAM START | 2013
PROGRAM Overview
To understand how members experience Comprehensive Medication Reviews (CMRs)
and to identify ways to improve effectiveness of this member touch point,
Blue Shield of California (BSC) deployed a survey in 2015 to Medicare
members who received a CMR. Overall, members reported high satisfaction
and value in reviewing their entire medication regimen with their pharmacists.
2,636
SURVEY
RESPONDENTS
Survey Objectives
> Evaluate the usefulness and acceptance of CMRs delivered to BSC members
> Learn how members assess their CMR experience
> Determine whether BSC members who received a CMR also received
the required Patient Takeaway
83%
of members who completed
the survey rated the CMR
at a 4/5 or a 5/5, with 61%
of all members rating the
service as a 5/5
High marks
78%
of members found the
CMR service to be helpful
Several pharmacists received at least five
perfect ratings for member experience.
We thank them for their excellent work:
24
OutcomesMTM® Trends Report | 2016
68%
of members planned to
share the results of the
CMR with his/her doctor
86%
of members who reported
receiving a recommendation
from their pharmacist
intend to follow it
Reducing High Risk Medication Use
Christine Sedky, Prescriptions Plus, Inc.
Stephen C. Lee, Rite Aid Pharmacy 05890
James Michael Winton, Vista Pharmacy & Winton’s Pharmacy
William Cowley, Rite Aid Pharmacy 06266
Andrew Cloutier, Bel Air Pharmacy 522
Closing a Gap in Therapy
Personal Pharmacist™ Marie Phan
Pavilions Pharmacy 2216 – Anaheim Hills, CA
Personal Pharmacist™ Inhae Leavitt
Walmart 1881 – Antelope, CA
While conducting a CMR, Marie noted that her patient was
using a high risk, over-the-counter sleep aid to help with
insomnia. She determined the patient’s insomnia was most
likely a side effect of a prescription medication she was taking
at night. Marie advised her to take the medication in the
morning to promote good sleep practices and to avoid an
unnecessary sleep medication. Her intervention helped the
patient avoid an unnecessary visit to the doctor to address
insomnia or issues related to the high risk medication.
During a CMR, Inhae discovered that a patient with a history
of heart attacks did not have a prescription for a quickacting medicine for chest pain. She recognized the patient
would benefit from having this medication on hand should
she experience symptoms of a heart attack in the future.
Inhae contacted the physician to recommend initiating
the chest pain medication. The physician agreed with her
recommendation and sent a prescription for the medication.
MTM Today
NETWORK PERFORMANCE
Adherence
Health plans, particularly Medicare plan sponsors, are turning to MTM as a way to improve members’ adherence to critical
therapies. The need for better ways to influence adherence behaviors drives development of new MTM services, including the
Adherence Monitoring Program. Leveraging the pharmacies where members fill their medications helps healthcare payors
impact quality measures and reduce avoidable use of medical services.
ADHERENCE IN MEDICARE
For Medicare Part D plans, CMS Star Ratings include three adherence-focused Patient Safety measures, each triple-weighted.
The table includes the average of the numeric and star values for each measure reported in the 2016 Star Ratings,
which are based on data from 1.1.2014 - 12.31.2014.
MAPD
Avg.
MAPD
Star Avg.
PDP
Avg.
PDP Star
Avg.
D12 - Medication Adherence for Diabetes Medications
77%
3.9
80%
2.7
D13 - Medication Adherence for Hypertension (RAS antagonists)
79%
4.1
82%
3.6
D14 - Medication Adherence for Cholesterol (Statins)
75%
4.0
78%
3.5
Measure Name
Adherence Monitoring Program
Designed for members at risk of non-adherence who may
benefit from extra attention, the Adherence Monitoring
Program (AMP) includes multiple pharmacist-patient
interactions throughout the year. Upon successful completion
of an enrollment TIP, the pharmacy is prompted with quarterly
checkpoints to provide ongoing support to help the patient
maintain adherence to the target medication. For members
who successfully complete each checkpoint and reach at
least 80% proportion of days covered (PDC), the pharmacy
receives a year-end performance bonus.
48%
of Targeted members
had a completed
enrollment TIP
In 2015, the first full year of AMP, services focused
on these three Star Patient Safety measures.
82% of members who Completed all AMP
72%
of all completed
TIPs resulted
in Successful
Enrollment
38%
of all Enrolled Members
finished the program and
were ≥80% Adherent
services were Adherent at year-end
some plans
achieved up to
55%
Centers for Medicare and Medicaid Services. “Medicare 2016 Part C & D Star Rating Technical Notes Draft.” Sept. 30, 2015.
https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2016-Technical-Notes-Preview-2-v2015_09_02.pdf
26
OutcomesMTM® Trends Report | 2016
For participating Medicare plan sponsors, an average of 38%
of members enrolled into AMP completed all
services and reached ≥80% PDC.
2016 | OutcomesMTM® Trends Report
27
Where is
MTM
Going?
28
OutcomesMTM® Trends Report | 2016
As we look forward to the remainder of 2016 and the years
beyond, intriguing changes are in store for MTM, pharmacy
and the healthcare industry.
> PDP plans selected for the Enhanced
MTM Model test will define their
interpretations of an innovative MTM
program that achieves both clinical and
cost benefits for a January 2017 launch.
> MTM will continue to appear in new
care models, and more healthcare payors
outside Medicare will adopt pharmacistdelivered MTM to help their members take
the right medications in the right way at
the right time.
> Pharmacist-delivered MTM services
will expand into new arenas, working
to solve some of healthcare’s biggest
concerns, such as helping patients stay
adherent to vital therapies and
preventing hospital readmissions.
> Now that the quantitative
CMR measure has arrived, discussion
will heat up around defining and
measuring the quality of CMRs
and other MTM services, along with
how to best determine the return
on resources invested in MTM.
> The role of pharmacists in healthcare
will evolve as more states grant provider
status. Pharmacists will fill in healthcare
gaps as our nation faces a shortage of
primary care physicians created by rapidly
increasing demand for healthcare services.
Through it all, more people will benefit from a pharmacist’s intervention. A young man will breathe a little easier when his pharmacist helps himimprove his inhaler
technique. Someone’s mother will avoid a dangerous fall when her pharmacist talks to the
physician about discontinuing a high risk medication. A woman’s husband will rejoin her in
their favorite pastimes when a pharmacist identifies a medication side effect as the cause
of debilitating symptoms.
2016 | OutcomesMTM® Trends Report
29
MTM Tomorrow
The Future of Healthcare
Over the past decade there has been a
dramatic increase in the percentage of pharmacists
who are performing healthcare-related services. 60%
of pharmacists provided MTM and 53% performed
immunizations in 2014, compared with only 13%
and 15%, respectively, in 2004.”
We are living longer than ever, and with long life comes extended years of care for chronic conditions. As new medications
come to market, they bring more opportunities for medication misuse, making accessible, high quality MTM services a
critical part of our healthcare future. The growing demand for healthcare services will also shift how those services are
delivered. As we face a potential shortage of physicians, other providers—including pharmacists—will step in to
provide basic healthcare as well as new MTM services.
- Pharmacy Workforce Center, Inc.8
50%
of patients walk out
of appointments not understanding
what they were told by their physician.1
By
2020
157M
$4.2 TRILLION.
90%
Patients actively participate in
their own clinical decision-making
81 million
<10% of the time.
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OutcomesMTM® Trends Report | 2016
Other healthcare practitioners may fill gaps in care:
Nurse Practitioners:
Growth from 2003 to 2014: 180%
NP graduates in 2014: 18,484
Physician Assistants:
Growth from 2003 to 2014: 74.7%
Number of newly certified PAs in 2014: 7,578
Pharmacists:
Growth from 2003 to 2014: 84.8%
Number of pharmacy graduates in 2014: 13,8385
2008
62%
2012
49%
2014
35%
The % of physicians describing
themselves as independent
practice owners is declining
Over 80 percent report that they are
overextended or at full capacity 6
Clinical pharmacists working for and
with Accountable Care Organizations
(ACOs) typically oversee MTM and patient
education, as well as transitioning care
from the hospital to the community.
> 43% of the ACOs surveyed do not employ a clinical pharmacist
> 40% of ACOs employ
a clinical pharmacist
> 17% contract with
an outside pharmacist7
98% of respondents think focus on
population health will increase in coming
years, which may increase the presence of
pharmacists in these care organizations.
2
will have multiple chronic illnesses.1
Bodenheimer, Thomas, Ellen Chen and Heather D. Bennett.
Confronting The Growing Burden Of Chronic Disease: Can The U.S.
Health Care Workforce Do The Job? http://content.healthaffairs.org/
content/28/1/64.full. Accessed Apr. 6, 2016
The cost burden of
chronic illness—
currently 78% of total
health spending—will
increase markedly by
2023 to an estimated
of adults over the age of
65 years take at least one
prescription drug.3
Pharmacists in
New Care Models
Within the next 10 years, there is
estimated to be a 27% shortage
of primary care physicians
(PCPs) in the U.S., about 90,000
fewer PCPs than the U.S.
healthcare system requires.4
1
Americans are
expected to be living with
a chronic condition.
1
PHARMACIST ROLES ARE ChANGING
Independent Physician
Practice Ownership
The need for MTM is growing
Since 2002 there has been a
15% increase in the number
of 55-64-year-olds taking
five or more medications.1
In 2014, more than 25% of hospitals and
other patient care settings had collaborative
practice agreements in place, thus allowing
pharmacists to expand their role as an
integral member of the patient’s
healthcare team.8
Bodenheimer, Thomas. A 63-Year-Old Man With Multiple Cardiovascular
Risk Factors and Poor Adherence to Treatment Plans.
http://personcentredcare.health.org.uk/sites/default/files/resources/
bodenheimer_clinicalcrossroadsjama.pdf. Accessed Apr. 8, 2016.
2
National Center for Health Statistics. Health, United States,
2012: With Special Feature on Emergency Care.
http://www.cdc.gov/nchs/data/hus/hus12.pdf.
Accessed Apr. 8, 2016.
3
4
The Conversation. “Can pharmacists help fill the growing primary care gap?.”
January 5, 2016. https://theconversation.com/can-pharmacists-help-fill-thegrowing-primary-care-gap-51015. Accessed Apr. 8, 2016.
5
Salsberg, Edward. “The Nurse Practitioner, Physician Assistant, And
Pharmacist Pipelines: Continued Growth.” May 26, 2015. http://healthaffairs.
org/blog/2015/05/26/the-nurse-practitioner-physician-assistant-andpharmacist-pipelines-continued-growth/. Accessed Mar. 8, 2016.
“The Landscape Of Physician Practice.” Health Affairs. March 2016
35:3388-389. http://content.healthaffairs.org/content/35/3/388.abstract.
Accessed Apr. 8, 2016.
6
Salazar, David. “PBMI releases first report on pharmacy trends in ACOs.”
Jan. 26, 2016. http://www.drugstorenews.com/article/pbmi-releasesfirst-report-pharmacy-trends-acos. Accessed Apr. 8, 2016.
8
Salazar, David. “PBMI releases first report on pharmacy trends in ACOs.”
Jan. 26, 2016. http://www.drugstorenews.com/article/pbmi-releasesfirst-report-pharmacy-trends-acos. Accessed Apr. 8, 2016.
7
2016 | OutcomesMTM® Trends Report
31
Part D Enhanced MTM Model Test
PROGRAM Overview
In September 2015, the Center for Medicare and Medicaid Innovations (CMMI) announced a test of new payment
models for MTM. Beginning in January, the Enhanced MTM Model will run from 2017-2021 for stand-alone
prescription drug plans (PDPs) under the Medicare Part D program. In five Part D regions, selected plan sponsors
will offer innovative MTM programs, aimed at improving the quality of care while also reducing costs.
Objective
Test whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will
engender enhancements in the MTM program, leading to improved therapeutic outcomes, while reducing
net Medicare expenditures
Measure
Evaluate the proportion of beneficiaries affected and MTM programs’ impact on:
> Patient outcomes and satisfaction
> Plan expenditures, including plan bids, and other Medicare spending
> Overall marketplace
Q:
What are the biggest trends
to watch as plan sponsors
implement under the model?
As plan sponsors test innovations in MTM models, they’ll learn and gain insight to inform their models in
future years. Given the tight window for application submissions, I don’t anticipate significant innovation
within the first year. However, as plans acquire experience with various approaches, I believe we’ll see
great progress in three key areas:
1)Fine-tuning risk stratification methods to vary intensity of MTM services based on beneficiary-specific needs
2) Further leveraging providers in their networks, both physicians and pharmacists, to drive optimal medication use
3) Standardizing the codification of MTM encounter data across the industry, which should provide opportunities
to benchmark models, drive best practices and improve outcomes tightly linked to medical spend
“We also believe that without
participation of retail
community pharmacists,
the testing of enhanced
MTM models will fall short
of achieving the maximum
potential in terms of positive
outcomes and impact on
beneficiary health.”
House Committee on Energy and
Commerce Subcommittee on Health
in a letter to Secretary of
Health and Human Services
Sylvia Burwell
MTM Tomorrow
MTM DEVELOPMENTS
Q: What can plan sponsors
do to support the success of
community pharmacies in
Enhanced Model programs?
Of course, they should include pharmacies in their program!
Community pharmacists offer scale and accessibility unlike
any other healthcare professional.
Beyond that, access to additional information, such as
diagnosis codes, labs and hospital discharge summaries,
can aid pharmacists in providing optimal MTM services.
Right now, available health information for a beneficiary
is typically limited to prescription medication records at
the pharmacy level. This may mean plan sponsors taking
a greater role in facilitating communication between
pharmacies, physicians and health systems, particularly by
supporting health information exchanges.
Q: What kinds of MTM services
do you foresee aligning best with
the goal of reducing Medicare
expenditures?
MTM services that are designed to manage and even reduce
medical utilization will align best. These services may include
medication reconciliation post transitions of care, intense
monitoring of patients taking medications commonly
linked to adverse events and services focused on optimizing
medication adherence. Of course, resolution of identified drug
therapy problems through consultation with members and
their prescribers will be key, just as it is in MTM programs today.
For more information on the Enhanced MTM Model, visit
https://innovation.cms.gov/initiatives/enhancedmtm.
Jessica Frank, VP of Quality
OutcomesMTM
32
OutcomesMTM® Trends Report | 2016
2016 | OutcomesMTM® Trends Report
33
MTM Tomorrow
MTM SPOTLIGHT
New MTM Models
As regulations and expectations for healthcare systems change, healthcare payors
are seeking new ways to improve care and outcomes for their members. Their
MTM programs are evolving as well, with integration into new care models and
multi-channel diversification.
PROGRAM Overview
Gaps in care, use of high risk medications, improper adherence, inappropriate dosing and
other medication-related issues all lead to poor outcomes, which, in turn, lead to higher
healthcare costs. To improve medication-related outcomes, BCBSRI integrated MTM into
the holistic care process with pharmacist interventions aimed at preventing, mitigating
and correcting drug therapy problems. Launched in 2014, the BCBSRI MTM program
utilizes both clinical pharmacists embedded in Patient Centered Medical Homes (PCMHs)
and a network of community pharmacists. All MTM services are documented through the
OutcomesMTM Connect™ Platform for unified reporting.
Blue Cross & Blue Shield of Rhode Island
Medicare + Commercial PROGRAM START | 2014
All CHANNELS
01.01.15-12.31.15
28,890
MTM Interventions
16,967
Increased Value
for Member
5,542
DTPs*
Resolved
Successful Interventions
11,977
Unique
Members
Served
$ 4,205,871
Estimated Cost
Savings
Provider
Part C Wellness
Participating Locations
Members Served
DTPs* Resolved
AIM Savings
*DTP = drug therapy problem
34
OutcomesMTM® Trends Report | 2016
6 PCMH
locations
Medicare Network
Medicare PCMH
Commercial Network
Commercial PCMH
283
6,269
2,283
$ 1,312,080
6
3,403
1,985
$ 1,837,164
552
1,826
964
$ 591,429
6
650
310
$ 465,199
NCM
Alternate
Services
CMR
TMR
Medical Spend
Star Ratings
Definitions:
NCM — Nurse Case Managers
CMR — Comprehensive Medication Review
TMR — Targeted Medication Intervention
Multiple
Pharmacist
Touchpoints
Pharmacy
DSM
TOC
Pharmacy Costs
Financial Gain
Direct
Financial
Benefits
4,053
Members
7,114
Successful
Interventions
=
Estimated
Savings
$2.3M
When Kenny first arrived, I was
not really sure how he was
going to help us at all. Now I am
going to struggle to remember
the innumerable ways he is
helping us. He has had a huge
positive impact on our diabetic
population. He provides diabetic
teaching, suggests dosage
adjustments based on sugar
readings, gets patients to call in
their sugar readings and sees them
in office to check on their progress.
He comes up with strategies to
help our diabetics who cannot
afford all their medicines, which is
a MAJOR issue in our practice. The
control of our diabetic population
has definitely improved due to
his efforts. He is a wealth of
information when questions
come up on drug interactions,
side effects and less costly
alternatives...He reminds us
of potential gaps in care for
patients: diabetics who are not
on statins, proteinuria without an
ACE inhibitor, etc. I have received
numerous positive comments of
appreciation from patients about
the ways our pharmacist has
helped them. I definitely
think you are getting
“bang for your buck” with
the in-office pharmacist.”
Robert Mathieu, MD
Internal Medicine
Providence Office of Anchor Medical
regarding his experience with
Kenny Correia, a pharmacist
serving three PCMH sites
DSM — Disease State Management
TOC — Transitions of Care
2016 | OutcomesMTM® Trends Report
35
MTM Tomorrow
MTM DEVELOPMENTS
Expanding the View of MTM
MedSync
Medication Synchronization
As healthcare stakeholders achieve success with pharmacist-delivered MTM and increase focus on quality of care
and reducing hospital admissions, MTM as we know it today is evolving into a broader concept. Medicaid plans,
commercial insurers, employer groups and even health systems are joining Medicare plan sponsors in looking at
MTM services in new, strategic ways.
Missed medication
doses cause
The MedSync service aligns a patient’s chronic medications to a common refill date
for a convenient monthly pick-up.
% of Americans with at least
one chronic disease by age group
(70 million individuals)2
Patient Benefits:
Simplifying the refill process can make managing multiple medications easier for
both patients and caregivers, with fewer refill dates to manage and reduced need
for transportation to the pharmacy. MedSync also complements other pharmacy
services to improve adherence, such as bubble packs or automatic refills.
Pharmacy Benefits:
Offering this beneficial service strengthens patient-pharmacist relationships as
well as customer satisfaction and loyalty. Talking with the patient at each monthly
pick-up may also present opportunities to complete additional MTM services.
Establishing regularly scheduled fills can improve operational efficiencies,
including staffing, inventory, workflow and delivery service.
125,000
DEATHS EVERY YEAR
and account for 10-25%
of hospital and
nursing home admissions.1
APhA Foundation. Align My Refills Infographic. http://www.aphafoundation.org/align-my-refills/infographic. Accessed April 7, 2016.
AARP. Chronic Conditions Among Older Adults. http://assets.aarp.org/rgcenter/health/beyond_50_hcr_conditions.pdf. Accessed April 7, 2016
3
New England Healthcare Insititute. Improving Patient Medication Adherence: A $290 Billion Opportunity. http://www.nehi.net/bendthecurve/sup/documents/Medication_Adherence_Brief.pdf. Accessed April 7, 2016.
1
2
36
OutcomesMTM® Trends Report | 2016
3
Health plan Benefits:
Synchronized fill dates improve adherence for chronic medications that impact
important quality ratings. When members take medications on time, they avoid
healthcare costs related to poor adherence, such as unnecessary doctor visits or
even hospitalizations.
57%
of non-adherent patients
enrolled at baseline became
adherent in a pilot for an
appointment-based model1
91%
adherence
rate
maintained by MedSync
patients in a 12-month study1
Adherence rates
are approximately
30%
higher
for patients with
synchronized medications
versus non-synchronized
medications2
1
APhA Foundation. Pharmacy’s Appointment Based Model Implementation Guide for Pharmacy Practices. http://www.aphafoundation.org/sites/
default/files/ckeditor/files/ABMImplementationGuide-FINAL-20130923.pdf. Accessed April 7, 2016.
2
National Community Pharmacists Association. Assessing the Impact of a Community Pharmacy-Based Medication Synchronization Program on
Adherence Rates. December 10, 2013. http://www.ncpanet.org/pdf/survey/2014/ncpa-study-results.pdf . Accessed April 7, 2016.
2016 | OutcomesMTM® Trends Report
37
MTM Tomorrow
MTM DEVELOPMENTS
Expanding the View of MTM
The transfer from hospital to home or another care facility creates opportunities for care breakdowns and
miscommunication that may have serious repercussions. Therefore, facilitating a successful transition of care
has become a particular focus area for quality ratings and healthcare organizations.
The Centers for Medicare and Medicaid Services (CMS) have targeted medication reconciliation and prevention
of readmissions as key strategic areas. To that end, a new Star measure was introduced for 2018 (based on 2016
performance) which holds Medicare Advantage (MAPD) plan sponsors accountable for medication reconciliation for
members experiencing transitions in care. Specifically, the Medication Reconciliation Post Discharge measure assesses
the percentage of discharges from acute or non-acute inpatient facilities for members 18 years of age and older for
whom medications were reconciled within 30 days of discharge.
MedRec
Medication Reconciliation
While a number of medication reconciliation programs have been tested, few scalable models exist today. Even fewer programs
historically have looked to community pharmacists as a resource for delivery of this critical service. Now, with nearly 20 million
Medicare beneficiaries enrolled in MAPD plans that are held accountable for medication reconciliation, the need for MedRec at
scale is a reality. This is just the beginning as healthcare payors across the spectrum look to new approaches to manage member
morbidity, mortality and costs associated with repeated readmissions.
To address this need, OutcomesMTM will launch a medication reconciliation offering, inclusive of community pharmacists,
remote telephonic pharmacists, new workflow processes and member and prescriber communication standards.
Benefits of MedRec
In a study on the effect of health
literacy in trauma discharge
summary understanding,
only 24%
had the reading
skills to adequately
comprehend their
dismissal summary.
Of patients in the study who were
readmitted within 30 days, 65% had
inadequate literacy for dismissal
summary comprehension.
Asad J. Choudhry, M.B.B.S. et al. Readability of discharge summaries:
with what level of information are we dismissing our patients? May 1,
2015. http://www.americanjournalofsurgery.com/article/S00029610(15)30040-4/abstract. Accessed Apr. 6, 2016
38
OutcomesMTM® Trends Report | 2016
1/5 of
~
hospitalized
Medicare
beneficiaries are
rehospitalized
within 30 days.
These rehospitalizations have been
estimated to account for
$44 billion
per year in
hospital costs.
Paul M. Stranges, et al. A Multidisciplinary Intervention for
Reducing Readmissions Among Older Adults in a Patient-Centered
Medical Home. Feb.19, 2015. http://www.ajmc.com/journals/
issue/2015/2015-vol21-n2/A-Multidisciplinary-Interventionfor-Reducing-Readmissions-Among-Older-Adults-in-a-PatientCentered-Medical-Home. Accessed Apr. 7, 2016.
~25% of
readmissions
are potentially
preventable.
High priority areas for
improvement efforts include:
> Improved communication
among healthcare teams and
between healthcare
professionals and patients
> Greater attention to patients’
readiness for discharge
> Enhanced disease monitoring
> Better support for patient
self-management
Andrew D. Auerbach, MD, MPH1, et al. Preventability and
Causes of Readmissions in a National Cohort of General
Medicine Patients. http://archinte.jamanetwork.com/article.
aspx?articleid=249884. Accessed Apr. 6, 2016.
The Patient:
The Pharmacy:
The Physician/Hospital:
The Health Plan:
> Better understands the new regimen
> Avoids potentially dangerous
medication mistakes by receiving
assistance with disposal of old
medications, closing prescriptions
for discontinued medications and
review of the regimen for potential
drug therapy problems
> Receives counseling on correct
use of new medications
> Accesses adherence support
through a variety of tools
and services found at the
local pharmacy
> Ensures pharmacy records are updated appropriately
> Gains additional insight into the patient’s health to provide high quality care
> Builds a strong customer relationship
> Matches the patient with
appropriate services, such as
MedSync, delivery, bubble
packaging, disease state
counseling, etc.
> Earns MTM revenue
> Benefits from the patient receiving
support in the correct use of
medications, which reduces
readmission for preventable
medication-related events
> Gains an open line of
communication between members
of the patient’s care team if any
medication-related concerns
are identified
> May experience efficiencies by
working with the patient’s
community pharmacy for
correct medication lists and support
in achieving the best medication
related outcomes
> Satisfies requirements for
related quality measures
> Supports adherence to critical
medications that impact other
quality ratings and patient outcomes
> Creates an additional contact point
with a healthcare professional
for one more opportunity to identify
medication-related problems
2016 | OutcomesMTM® Trends Report
39
MTM Tomorrow
MTM SPOTLIGHT
The ROI of MTM
SERVICE CATEGORY
Passport Health Plan Medicaid Pilot
resulted in a
completed CMR
PROGRAM START | 2014
PROGRAM Overview
Passport Health Plan is a local, nonprofit community-based health plan that
administers Kentucky Medicaid benefits. The plan enrolled a select group of 1,000
members to test the impact of local pharmacists delivering MTM services. In addition
to resolving drug therapy problems, focus was placed on reducing drug product costs.
Following the first year of the program, Passport Health Plan conducted its own ROI
analysis. Results were nearly equal to the ROI calculated from the OutcomesMTM
Actuarial Investment Model (AIM™), which estimates avoided healthcare costs from
mitigating drug therapy problems.
Results
OVERALL ROI
145
PARTICIPATING
PHARMACIES
$9.82 : $1
550
Based on OutcomesMTM AIM™estimates
members
SERVED
OVERALL ROI
$9.43 : $1
11.01.14 -10.31.15
(ROI):
Calculated using the OutcomesMTM
Actuarial Investment Model (AIM™)
40
OutcomesMTM® Trends Report | 2016
LEVEL
Based on Passport Health Plan analysis
Return on Investment
CMRs = 27.7%
Patient Ed/Monitoring = 1.5%
Patient Consultation = 50.8%
Prescriber Consultation = 20%
73%
MTM continues to expand beyond Medicare. An increasing number of Medicaid
programs are finding value in MTM services delivered by local pharmacists.
Adherence
Support
REDUCED
Medication
COSTs
PREVENTED
A PHYSICIAN
VISIT
PREVENTED
AN ADDITIONAL
PRESCRIPTION
ORDER
The MTM pilot falls right
in line with our mission
to improve health and
quality of life for our members,
and it resulted in really positive
outcomes for patients with complex
conditions. It’s so encouraging to
us as pharmacists and healthcare
professionals to see Medicaid
members getting the appropriate
care and support they need.
- Carrie Armstrong, PharmD, MBA
Pharmacy Program and Analytics Manager, Passport Health Plan
PREVENTED
EMERGENCY
ROOM VISIT
PREVENTED
HOSPITAL
ADMISSION
PREVENTED A
LIFE-THREATENING
SITUATION
PRESCRIBER
CONSULTATIONS
PATIENT ADHERENCE
CONSULTATIONS
Successful = 42.7%
Refusals = 28.9%
Unable to Reach = 28.4%
Successful = 40.6%
Refusals = 27.3%
Unable to Reach = 32.1%
Based on the severity level of the intervention, AIM assigns an estimated cost
avoidance (externally validated by an actuarial firm) to each MTM claim.
2016 | OutcomesMTM® Trends Report
41
Restoring Quality of Life
Personal Pharmacist™ Lauren Adair, Patient Engagement Team, West Des Moines, IA
During a CMR, the patient’s wife told Lauren that her husband was no
longer able to walk on the beach with her. His uncontrolled COPD and
breathing made the stairs to the beach too difficult. They had seen
numerous doctors to run many expensive tests, but no one could find a
cause. The patient qualified for a Suboptimal Drug TIP regarding a heart
medication that sometimes exacerbates breathing problems in patients
with asthma or COPD. When Lauren suggested this medication could be
contributing to the patient’s poor condition, the patient’s wife confirmed
his symptoms started less than a week after he switched to the current
medication. Lauren faxed the patient’s doctor, and the wife said
she would bring it up during an appointment that week.
The patient transitioned to another medication, and his wife reported
dramatic improvement when Lauren followed up. The couple was back
to their walks on the beach.
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OutcomesMTM® Trends Report | 2016
MTM Tomorrow
Numbers, dollars and ratings are important factors in MTM, but the most vital measure
of success remains the impact on people’s lives.
The Face-to-Face Difference® is
the cornerstone of OutcomesMTM.®
Relationships—both within our organization and outside it—enable our employees,
network pharmacists, client health plans and their members to thrive.
2016 MTM Trends Report
© 2016 OutcomesMTM® | All rights reserved.
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OutcomesMTM® Trends Report | 2016