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Beyond Disease
Management
An Introduction to
Medication Therapy Management
Services
Why Do We Even Care?
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Over 100 million Americans suffer from one or more
chronic illnesses and 40 million are limited by them
Despite annual spending of nearly $1 trillion & significant
advances in care, one-half or more patients still don’t
receive appropriate care
Gaps in quality care lead to more than 57,000 avoidable
deaths per year
Better use of best practice medical care could avoid nearly
41 million sick days and more than $11 billion annually in
lost productivity
Patients and families increasingly recognize the defects in
their care
Source: www.improvingchroniccare.org/change/model/modeltalk.html
Why Do We Even Care?
Average Number of Unproductive Hours by Condition*
Condition
Average Number of Unproductive Hours in a
Typical 8-Hour Work Day
Heart Disease
4.3
Respiratory Infection
4.1
Diabetes
4.0
Migraine
3.4
High Blood Pressure
3.4
Arthritis
3.2
Allergies
2.8
High Stress
2.3
Anxiety
2.2
Depression
2.2
Why Do We Even Care?
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15-24% of hypertensives are controlled
42% of diabetics have controlled lipid levels
35% of eligible patients with atrial fibrilation
receive anticoagulation
25% of people with depression are receiving
adequate treatment
44% of discharged CHF patients are readmitted
within 120 days
Source: www.improvingchroniccare.org/change/model/modeltalk.html
Why is This?
Systems are perfectly
designed to obtain
the results they
achieve
How Can It Be Fixed?
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IOM Quality Report
“The current care systems cannot do the job.”
 “Trying harder will not work.”
 “Changing care systems will.”
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Conclusion: We must transition the current
healthcare system from one focused on “crisis
management” to one focused on the big picture.
Disease Management Components
Population identification processes;
 Evidence-based practice guidelines;
 Collaborative practice models to include physician and supportservice providers;
 Patient self-management education (may include primary
prevention, behavior modification programs, and
compliance/surveillance);
 Process and outcomes measurement, evaluation, and management;
 Routine reporting/feedback loop (may include communication
with patient, physician, health plan and ancillary providers, and
practice profiling).
* Note: Full-service disease management programs must include all six components.
Programs consisting of fewer components are disease management support services.
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Source: Disease Management Association of America (www.dmaa.org)
Beyond Disease Management
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Many initiatives now moving away from
“disease management”
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Phrase dehumanizes the patient
Focus should be on taking care of the patient, not a
disease that they possess
 Wellness programs
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Don’t just focus on the patient, but the whole
patient
Number of Chronic Conditions per
Medicare Beneficiary
Number of
Conditions
0
1
2
3
4
5
6
7+
Percent of
Beneficiaries
18
19
21
18
12
7
3
2
Percent of
Expenditures
1
4
11
18
21
95%
63%
18
13
14
Source: www.improvingchroniccare.org/change/model/modeltalk.html
The Chronic Care Model
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Model development began in 1993
Developed from
Extensive literature review
 Information obtained via intensive interviews with
72 “best practices”
 Input from an 40 member advisory committee
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Model applied with diabetes, depression,
asthma, CHF, CVD arthritis, AIDS, preventive
care and geriatrics
The Chronic Care Model
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Initially, researched diabetes management programs and
found that intervention types fall into four general domains:
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Decision support
Clinical Information systems
Self-management support
Delivery system design
Generally, the more of these domains a program contains,
the better the results
Subsequent reviews of programs dealing with other
conditions reinforced these elements and additionally
highlighted the importance of planned encounters and
better use of non-physician team members in facilitating
delivery system design
Source: www.improvingchroniccare.org/change/model/modeltalk.html
The Promise of
Team-Based Medicine
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The team approach is really our only hope for
sustaining our healthcare system into the future
due to factors* including:
Expanding pace and scope of discovery in medical
science and technology
 The growing complexity of medical care
 Increasing number of Americans with chronic
illnesses (and their changing expectations)
 Resource constraints
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*From Chaos to Care: The Promise of Team-Based Medicine.
David Lawrence, MD. Chairman Emeritus, Kaiser Permanente
Source: www.improvingchroniccare.org
The Chronic Care Model
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Clinical Information Systems - Organize
patient and population data to facilitate efficient
and effective care
Identify relevant subpopulations for proactive care
 Provide timely reminders for providers and patients
 Facilitate individual patient care planning
 Share information with patients and providers to
coordinate care (2003 refinement)
 Monitor performance of practice team and care
system
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Source: www.improvingchroniccare.org
Poor
Fair
Good
Poor
Fair
Good
The Chronic Care Model
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Decision support - Promote clinical care that is
consistent with scientific evidence and patient
preferences.
Use proven provider education methods
 Embed evidence-based guidelines into daily clinical
practice
 Share evidence-based guidelines and information with
patients to encourage their participation
 Integrate specialist expertise and primary care
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Source: www.improvingchroniccare.org
Poor
Fair
Good
The Chronic Care Model
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Delivery system design - Assure the delivery of
effective, efficient clinical care and selfmanagement support
Define roles and distribute tasks among team members
 Use planned interactions to support evidence-based care
 Ensure regular follow-up by the care team
 Provide clinical case management services for complex
patients (2003 refinement)
 Give care that patients understand and that fits with
their cultural background (2003 refinement)
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Source: www.improvingchroniccare.org
Poor
Fair
Good
The Chronic Care Model
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Self management support - Empower and
prepare patients to manage their health and health
care
Emphasize the patient’s central role in managing their
health
 Use effective self-management support strategies that
include assessment, goal-setting, action planning,
problem-solving and follow-up
 Organize internal and community resources to provide
ongoing self-management support to patients
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Source: www.improvingchroniccare.org
Poor
Fair
Good
Why Do Pharmacists Need to be on
the Healthcare Team?
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80/20 rule – 20% of the patients are responsible
for 80% of the costs
Who are the “20 percenters”? Patients with:
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Diabetes?
Heart Disease?
Cancer?
And now… a “New Disease”
The “New Disease”
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Yearly costs in excess of $177 billion (1999)
5th leading cause of death in the US
Behind heart disease, cancer, stroke and respiratory
disease
 Attributable to more deaths than diabetes,
Alzheimer's, kidney disease, breast cancer and AIDS
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Highly preventable
What’s the “disease”?
The New “Disease”?
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Adverse Drug Reactions
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Many of the medications that we take actually end up
causing more problems than they solve because they are
not prescribed, used, or monitored appropriately
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We actually spend more money in the US dealing with
the problems that medications cause than we spend on
the medications themselves
Contributing Factors
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Increases in:
Numbers of people with chronic conditions (asthma,
allergies, diabetes, hypertension, hyperlipidemia, etc.)
 Numbers of treatment options
 False sense of security
 Demands on physician time
Reinforcing a “crisis
management healthcare system”
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A New Kind of “High-Risk”
(& High-Cost) Individual
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NOT someone with a specific disease
NOT someone on a specific medication
Someone who takes multiple medications and has
multiple chronic conditions – Predisposed to:
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Multiple providers
Fragmented care
Interactions – Drug/drug, drug/disease, drug/age
Inappropriate/unnecessary prescriptions
Inadequate monitoring for efficacy and toxicity
Non-compliance/inappropriate use
Suboptimal outcomes
Pharmacists: An Untapped Resource
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All these individuals have a common root
problem:
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Inadequate oversight/monitoring of complex drug
regimens consisting of multiple medications that
have the potential to adversely effect each other’s
actions as well as the individual’s chronic conditions
Who better to deal with these situations than a
pharmacist?
Pharmacists: An Untapped Resource
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Pharmacists receive more training on the safe,
effective and appropriate use of medications
than any other healthcare professional
The only pharmacy degree offered in the United
States is the Doctor of Pharmacy or PharmD
Pharmacists are the most accessible healthcare
provider, yet few individuals ever have
meaningful interactions with a
pharmacist…Why?
Why is This?
Systems are perfectly
designed to obtain
the results they
achieve
Pharmacists: An Untapped Resource
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“Closed” healthcare systems like Kaiser and the
VA have had great success integrating
pharmacists into the healthcare team
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Virtually all other health plans and PBMs view
pharmacists as someone who facilitates drug
distribution
Pharmacists cannot get paid out of the medical benefit
 Pharmacies only get paid if an Rx goes out the door
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Strategies for Delivering MTM
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Two basic types of Medication Therapy
Management (MTM) Services
Dispensing-related: Brief therapy-specific
interventions designed to take advantage of the
pharmacist’s unparalleled patient access
 Non-dispensing related: More time-intensive
encounters that leverage the pharmacist’s unique
expertise in reviewing complex drug regimens to
assess for appropriateness; monitor for efficacy,
adverse reactions and drug interactions; promote
compliance and appropriate use, etc.
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Dispensing Related MTMS
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Pharmacist is responsible for identifying which
patients need what services
Realign the financial incentives at the pharmacy to
promote safe, effective and appropriate medication
use rather than simply fast, cheap and accurate
dispensing.
Con – Counter to how
Pro – Reach a large
population of individuals. pharmacy payment systems
are set up.
Difficult for to target
services specifically to
individuals w/greatest need
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Dispensing Related MTMS
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Example :
A patient presented to a pharmacy with two new
prescriptions for the same diabetes medication. The
pharmacist noted that the two prescriptions used together
would likely result in an overdose. The pharmacist
contacted the doctor to clarify the dosing regimen. The
physician had intended for the patient to use one
prescription during the first month and the other
prescription as a dose increase for the second month. The
pharmacist educated the patient according to the doctor’s
instructions and averted a potentially life-threatening
situation.
NON-Dispensing Related MTMS
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More intensive services for patients who are high-risk
Services are arranged by appointment (not at the pharmacy
counter…not even necessarily in the pharmacy)
Pharmacists review patient’s profile, meet with patient
(preferably in person), identify and address barriers to
appropriate, cost-effective care
Recommendations sent to patient’s healthcare team for
consideration and action as appropriate/necessary
Pro – Direct applicability
to chronic care model.
Ability for push vs. pull
Con – Model needs
development and support
NON-Dispensing Related MTMS
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Example:
A Pharmacist conducts a Comprehensive
Medication Review for a patient taking multiple
medications. During the review the pharmacist
found the patient was taking seven prescription
drugs along with twelve over-the-counter products.
In reviewing these medications, the pharmacist
identified and resolved nine drug therapy
complications of various severities – including three
to lower drug costs and one which potentially
averted an ER visit.
Hybrid Model
Semi-Dispensing Related MTMS
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Someone else (payer, PBM, plan, etc) identifies
which specific patients are in need of certain
medication-related interventions and refers them
to the patient’s pharmacy for execution
Pro – Leverages existing
local relationships
between pharmacists and
their patients & other
providers
Con – Questionable
compatibility with current
community pharmacy
business model
Semi-Dispensing Related MTMS
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Example :
A PBM mines their pharmacy claims data and identifies a patient
who appears to be non-compliant with their Coumadin therapy.
The pharmacy where the patient obtained the medication in
question is told that they should have a pharmacist contact the
patient and investigate the potential compliance problem. The
pharmacist calls the patient and finds out that he often forgets to
take his medication in the morning. After some discussion, the
pharmacist identifies that the first thing the patient does every
morning is make a pot of coffee. The pharmacist recommends that
the patient keep their bottle of Coumadin by the coffee pot and
commit to not making coffee until their medication is taken.
Patient agrees and doesn’t miss another dose. Pharmacist
documents intervention, submits claim to PBM which pays the
pharmacy $20 for the intervention.
Evidence of Value
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Dispensing-related MTMS
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Florida Medicaid
 Community Pharmacist Identification and
management of Quality Related Events (QREs)
 Average estimated costs avoided per dollar paid:
$15.57
Non-Dispensing related MTMS
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Iowa Medicaid - Pharmaceutical Case Management
Program
 Pharmacists and physicians make MTM appointments
with high risk patients
 Significant improvements in medication safety without
any increases in overall healthcare costs
Evidence of Value
 Wyoming
PharmAssist Program
 Residents
who have concerns about their meds
are scheduled a one-on-one visit with a
pharmacist who look for potential interactions,
duplications, cost savings opportunities, etc.
 Patients saved an average of $155 per month
 Asheville
Project
The Asheville Project…
In the Beginning
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Initial point of discussion in 1994 was a diversionary
tactic to get hospital and community pharmacists to stop
fighting over discriminatory pricing
“Partnering” with hospital system, PBM, NCAP, NCCPC,
UNC & Campbell Schools of Pharmacy
Invitation to all pharmacists in community in 1996
Responses of independents vs. chains
Two weekends (32 hours) of training by physicians and
diabetes educators
Compensation after results
Patient Incentives and
Care Model
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Patient recruitment in 1997
Incentives
 Glucose meters
 PBM co-pay waivers
 Labs without co-pays
MD Collaboration & “buy in”
Patient education & community resources — Mission
+ St. Joseph’s Diabetes Center
Matching patients to pharmacists for Medication
Therapy and Case Management
Direct Medical Costs in
The Asheville Project
1997
1998
1999
2000
2001
2002
Average net annual savings: $1,600-$3,200 per diabetic participant from 1998 on
Patient Behaviors Over Time in
The Asheville Project
The “Asheville Project” Today
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Program began in 1997 with 49 people with diabetics
employed by the City of Asheville working with
community RPh’s, the Diabetes Education Center and
physicians
Now over 1800 patients from 10 employers are enrolled
for diabetes, asthma, hypertension and lipid therapy
management and depression
50% reduction in sick days in the first year
Employers have saved over $5,000,000 dollars in health
care costs
Now several pharmacists do this as their job and there are
pharmacy residents for the program in addition to
community pharmacists
Conclusions
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Follow the dollars and you’ll never get lost
Ask prospective vendors if/how they employ the 4
critical components:
Clinical Information systems
 Decision support
 Delivery system design
 Self-management support
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Place critical importance on
Strategies aimed at utilizing existing providers and
relationships through promotion of practice change
 Ability to use team-based care & community resources
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Questions?