Medication Therapy Medication Therapy ManagementManagement

Sample Presentation: Given to Local EmployerSample Presentation: Given to Local Employer

BackgroundBackground

The Need for Medication Therapy The Need for Medication Therapy ManagementManagement

Prescription drug spending in the United Prescription drug spending in the United States was $252 billion in 2005States was $252 billion in 2005

Medicare Part D will add $700 billion Medicare Part D will add $700 billion over the next 10 yearsover the next 10 years

Prescription drug spending has grown Prescription drug spending has grown by an average annual rate of 11-15% by an average annual rate of 11-15% over the past 5 yearsover the past 5 years

BackgroundBackground

The cost of drug therapy related morbidity and The cost of drug therapy related morbidity and mortality is the 5mortality is the 5thth most costly health condition most costly health condition

The cost related ratio is for every $1.00 spent The cost related ratio is for every $1.00 spent on medication an additional $1.30 is spent on medication an additional $1.30 is spent managing drug therapy problemsmanaging drug therapy problems

The estimated 2000 cost was $177 billionThe estimated 2000 cost was $177 billion Institute of Medicine July 2006 reportInstitute of Medicine July 2006 report Several organization including CMS, NCQA, and Several organization including CMS, NCQA, and

others have called for actionothers have called for action

Johnson JA, Bootman JL: Arch Intern Med 1995;155:1949 and Johnson JA, Bootman JL: Arch Intern Med 1995;155:1949 and Ernst FR et al. J Am Pharm Assoc 2001;41:192Ernst FR et al. J Am Pharm Assoc 2001;41:192

COSTS OF DRUG COSTS OF DRUG THERAPY PROBLEMSTHERAPY PROBLEMS

Total U.S. Costs = $177 billion / yearTotal U.S. Costs = $177 billion / year

Physician/Urgent Care VisitsPhysician/Urgent Care Visits $ 14 billion$ 14 billion +Added Medications+Added Medications $ 3 billion$ 3 billion +Emergency Room Visits+Emergency Room Visits $ 6 billion$ 6 billion +Hospital Visits+Hospital Visits $ 121 billion$ 121 billion +Long-term Care Stays+Long-term Care Stays $ 33 billion$ 33 billion

Ernest FR and Grizzle AJ. Drug-Related Morbidity and Mortality: Updating Ernest FR and Grizzle AJ. Drug-Related Morbidity and Mortality: Updating the Cost-of-Illness Model J. APhA 41: March 2001.the Cost-of-Illness Model J. APhA 41: March 2001.

Business CaseBusiness Case

WHO Definition of a Healthy WHO Definition of a Healthy WorkforceWorkforce

Four Key AttributesFour Key Attributes• HealthyHealthy

• ProductiveProductive• ReadyReady

• ResilientResilient

Business CaseBusiness CaseFocus of Pharmaceutical CostsFocus of Pharmaceutical Costs

FocusFocus Unit PricingUnit Pricing UtilizationUtilization Therapuetic Therapuetic MixMix

StrategyStrategy Volume Volume

PurchasingPurchasing

Financial Financial incentives for incentives for key stakeholderskey stakeholdersAccess controlAccess control

Substitution Substitution based on costbased on cost

TacticsTactics

Pharmacy Pharmacy

ManagementManagement

ConsolidationConsolidationRestrict Restrict formularies/ formularies/ contractingcontracting

Benefit designBenefit designPrior Prior authorizationauthorization

Generic Generic substitution substitution “step care”“step care”

Now Which Way?Now Which Way?

ValueManagement

CostManagement

Cost ManagementCost Management

Carve out silo managementCarve out silo management

Focus on unit priceFocus on unit price– Ties copayment to acquisition priceTies copayment to acquisition price

Limit accessLimit access

Value ManagementValue Management

Focus on cost/benefitFocus on cost/benefit

Access based on evidence of valueAccess based on evidence of value

Financing based on ROI to payerFinancing based on ROI to payer

Impact of Health on Impact of Health on ProductivityProductivity

Average Number of Unproductive Hours by Condition in Average Number of Unproductive Hours by Condition in a Typical 8 Hour Work Day*a Typical 8 Hour Work Day*

ConditionConditionHeart DiseaseHeart Disease 4.34.3Respiratory InfectionRespiratory Infection 4.14.1DiabetesDiabetes 4.04.0MigraineMigraine 3.43.4High Blood PressureHigh Blood Pressure 3.43.4ArthritisArthritis 3.23.2AllergiesAllergies 2.82.8High StressHigh Stress 2.32.3Anxiety Anxiety 2.22.2DepressionDepression 2.22.2

On days when affected by the condition/Sample On days when affected by the condition/Sample size = 563 Source: Medstatsize = 563 Source: Medstat

Value Proposition for a Value Proposition for a Medication Therapy Medication Therapy Management as a BenefitManagement as a Benefit

Proper use of medications can lead to improved Proper use of medications can lead to improved health, enhanced quality of life, and increased health, enhanced quality of life, and increased productivityproductivity

Overuse, under-use, and misuse of drugs is linked Overuse, under-use, and misuse of drugs is linked to reduced health, poor quality of life, and to reduced health, poor quality of life, and decreased productivitydecreased productivity

Clinical pharmacists with advanced training can Clinical pharmacists with advanced training can reduce drug therapy problems and improve reduce drug therapy problems and improve health and economic outcomeshealth and economic outcomes

Patient-centered MTM services have consistently Patient-centered MTM services have consistently provided a $4:$1 ROI*provided a $4:$1 ROI*

* Sources* SourcesWilcox S, Himmelstein D, Wolhander S: JAMA 1994;272:292-296Wilcox S, Himmelstein D, Wolhander S: JAMA 1994;272:292-296Col N, Finale J, Kronhom P: Arch Intern Med 1990;150:841-845 Col N, Finale J, Kronhom P: Arch Intern Med 1990;150:841-845

Isetts B, Brown L, Schondelmeyer S, Lenarz L: Arch Intern Med 2003;163:1813-1820Isetts B, Brown L, Schondelmeyer S, Lenarz L: Arch Intern Med 2003;163:1813-1820Zarowitz B, Stebelsky L, Muma B, Romain T: Pharmacotherapy 2005;25(11):1636-1645Zarowitz B, Stebelsky L, Muma B, Romain T: Pharmacotherapy 2005;25(11):1636-1645

Garrett D, Bluml B: J Am Pharm Assoc 2005;45:130-137Garrett D, Bluml B: J Am Pharm Assoc 2005;45:130-137Cranor C, Christensen D: J Am Pharm Assoc 2003;43:160-172Cranor C, Christensen D: J Am Pharm Assoc 2003;43:160-172

Malone DC et al. Pharmacotherapy 2000;20:1149Malone DC et al. Pharmacotherapy 2000;20:1149

ObjectivesObjectives

Transition the perspective of pharmacy benefit to:Transition the perspective of pharmacy benefit to: Enhance employee satisfactionEnhance employee satisfaction Improve employee performanceImprove employee performance Improve economic outcomesImprove economic outcomes Change the pharmacy care model to one of Change the pharmacy care model to one of

action and prevention not reactionaction and prevention not reaction Improve targeting of drug therapy problemsImprove targeting of drug therapy problems Improve health statusImprove health status Establish multi-risk focused interventions for Establish multi-risk focused interventions for

drug therapy managementdrug therapy management Develop a framework that is employee-centricDevelop a framework that is employee-centric Integrate MTM into the mainstream of corporate Integrate MTM into the mainstream of corporate

health carehealth care

MTM Process of Care MTM Process of Care OverviewOverview

Patient-centeredPatient-centered Consistent and systematic processes that:Consistent and systematic processes that:

– Assess all of the patient’s drug-related needsAssess all of the patient’s drug-related needs– Identifies drug therapy problemsIdentifies drug therapy problems– Establishes therapeutic goalsEstablishes therapeutic goals– Designs a medication therapy care planDesigns a medication therapy care plan– Conducts follow-up visits to evaluate Conducts follow-up visits to evaluate

progressprogress– Communicates information to the patient’s Communicates information to the patient’s

physician or nurse provider in a collaborative physician or nurse provider in a collaborative practicepractice

GoalsGoals

IndividualizedIndividualized Establish desired goals of therapy for each Establish desired goals of therapy for each

drug and measurement parametersdrug and measurement parameters Mutual negotiation with the patient and Mutual negotiation with the patient and

health care providers when appropriatehealth care providers when appropriate Goals are realistic based on patient’s abilityGoals are realistic based on patient’s ability Establish timelinesEstablish timelines Optimize the patients medication therapy Optimize the patients medication therapy

experienceexperience

Several recommendations of the Institute of MedicineSeveral recommendations of the Institute of Medicine

Standardized Standardized AssessmentAssessment

Assessment parametersAssessment parameters Information about particular drug therapiesInformation about particular drug therapies Information about non-drug therapiesInformation about non-drug therapies Changes in drug regimensChanges in drug regimens Instructions for drug administrationInstructions for drug administration Medications and products the patient requiresMedications and products the patient requires Assistance with drug administration devicesAssistance with drug administration devices Information from other healthcare agenciesInformation from other healthcare agencies Referrals to other practitionersReferrals to other practitioners

Categories of Drug Therapy Categories of Drug Therapy ProblemsProblems

Every drug the patient receives Every drug the patient receives undergoes the following undergoes the following

evaluation:evaluation:

Assessment of proper indicationAssessment of proper indication– Is the drug being used unnecessaryIs the drug being used unnecessary– Is additional drug therapy neededIs additional drug therapy needed

Effectiveness of treatmentEffectiveness of treatment– The current drug therapy is ineffectiveThe current drug therapy is ineffective– The dose is too low to produce the The dose is too low to produce the

desired responsedesired response

Categories of Drug Therapy Categories of Drug Therapy ProblemsProblems

SafetySafety– Is there an adverse drug reaction Is there an adverse drug reaction

presentpresent– Is the current drug dosage too highIs the current drug dosage too high

Convenience Convenience – Is the patient adherent to the Is the patient adherent to the

therapytherapy– Are there barriers to the patient’s Are there barriers to the patient’s

ability to comply with therapy e.g. ability to comply with therapy e.g. physical, financialphysical, financial

Drug Therapy Problems IdentifiedDrug Therapy Problems Identified(n=5,136 patients)(n=5,136 patients)

Number Number of Drug of Drug Therapy Therapy ProblemsProblems

% of % of Drug Drug

Therapy Therapy ProblemsProblems

IndicationIndication Unnecessary Drug Unnecessary Drug TherapyTherapy

Needs Additional Drug Needs Additional Drug TherapyTherapy

688688

3,2463,2466%6%

28%28%

EffectivenessEffectiveness Ineffectve DrugIneffectve Drug

Dosage too LowDosage too Low882882

2,3282,3288%8%

20%20%

SafetySafety Adverse Drug ReactionAdverse Drug Reaction

Dosage too HighDosage too High1,7041,704

60260214%14%

5%5%

ComplianceCompliance NoncomplianceNoncompliance 2,2762,276 19%19%

TOTAL:TOTAL: 11,72611,726 100%100%Data from Medication Management Services, Inc.

ExperienceExperience

The Service Value The Service Value PropositionProposition

High satisfaction with this care modelHigh satisfaction with this care model 95% physician acceptance of care 95% physician acceptance of care

recommendations by pharmacistsrecommendations by pharmacists Data documented a 50% improvement in Data documented a 50% improvement in

patients meeting their therapeutic goalspatients meeting their therapeutic goals Positive impact on health system utilization and Positive impact on health system utilization and

employee productivity including:employee productivity including:– Reduction in hospitalization / clinic / ER visitsReduction in hospitalization / clinic / ER visits– Identification and resolution of drug therapy Identification and resolution of drug therapy

problemsproblems– Employee days savedEmployee days saved

Example Practice Profile Example Practice Profile for a Medication Therapy for a Medication Therapy Management ServiceManagement Service

Demographic SummaryDemographic Summary

700 Active Patients700 Active Patients 1500 Documented Visits1500 Documented Visits 60% female and 40% males60% female and 40% males Average age = 62 years oldAverage age = 62 years old Average number of medical conditions Average number of medical conditions

= 6= 6 Average number of medications = 10Average number of medications = 10

The Most Frequent Indications The Most Frequent Indications for Drug Therapy in Practicefor Drug Therapy in Practice

1. Hypertension1. Hypertension2. Hyperlipidemia2. Hyperlipidemia3. Peptic Ulcer Disease3. Peptic Ulcer Disease4. Allergic Rhinitis4. Allergic Rhinitis5. Diabetes5. Diabetes6. Osteoporosis6. Osteoporosis

7. Pain-general7. Pain-general8. Arthritis Pain8. Arthritis Pain9. Prevention MI/Stroke9. Prevention MI/Stroke10. Hypothyroidism10. Hypothyroidism11. Depression11. Depression12. Insomnia12. Insomnia

These 12 conditions represent 52% of all indications for drug therapy

Sources of MedicationsSources of Medications

In addition to their prescription In addition to their prescription medications:medications:

502 patients (72%) were taking 2010 502 patients (72%) were taking 2010 different OTC medicationsdifferent OTC medications

19 patients were taking 36 different 19 patients were taking 36 different medications they received from friends or medications they received from friends or family membersfamily members

21 patients were also using 43 different 21 patients were also using 43 different sample products to manage their medicalsample products to manage their medical conditionsconditions

Practice AnalysisPractice Analysis(n = 700 patients)(n = 700 patients)

724 drug therapy problems were 724 drug therapy problems were identified and resolvedidentified and resolved

385 patients (55%) had 385 patients (55%) had >> 1 drug 1 drug therapy problemtherapy problem

98 patients (14%) had 98 patients (14%) had >> 3 drug 3 drug therapy problemstherapy problems

Drug Therapy Problems Drug Therapy Problems IdentifiedIdentified

% of Drug % of Drug Therapy Therapy ProblemsProblems

IndicationIndication Unnecessary Drug TherapyUnnecessary Drug Therapy

Need Additional Drug TherapyNeed Additional Drug Therapy12%12%

26%26%

EffectivenessEffectiveness Ineffective DrugIneffective Drug

Dosage too LowDosage too Low9%9%

17%17%

SafetySafety Adverse Drug ReactionAdverse Drug Reaction

Dosage too HighDosage too High19%19%

10%10%

ComplianceCompliance NoncomplianceNoncompliance 7%7%

Total Number of Drug Therapy Total Number of Drug Therapy Problems: 724Problems: 724

Ten Most Common Drug Ten Most Common Drug Therapy Therapy Problems and Associated Problems and Associated Medical ConditionsMedical Conditions

Dosage too low Dosage too low HypertensionHypertension Needs additional drug therapy Needs additional drug therapy Allergic rhinitisAllergic rhinitis Adverse drug reaction Adverse drug reaction HypertensionHypertension Dosage too low Dosage too low Arthritis PainArthritis Pain Adverse drug reaction Adverse drug reaction Arthritis PainArthritis Pain Adverse drug reactionAdverse drug reaction HyperlipidemiaHyperlipidemia Needed additional drug therapy Needed additional drug therapy DepressionDepression Dosage too low Dosage too low Allergic rhinitisAllergic rhinitis Needed additional drug therapy Needed additional drug therapy Angina pectorisAngina pectoris Needed additional drug therapyNeeded additional drug therapy EsophagitisEsophagitis

Program OutlineProgram Outline

Eligibility of 4 or more drugs or 2 or more Eligibility of 4 or more drugs or 2 or more chronic illnesschronic illness

6 – 8 service sites6 – 8 service sites Active employees and retirees Active employees and retirees Program would be voluntary and Program would be voluntary and

participants would consent to the programparticipants would consent to the program Participants would not be assessed a Participants would not be assessed a

copayment for pharmacist visitscopayment for pharmacist visits Incentives to participateIncentives to participate

– Reduction in medication copaymentsReduction in medication copayments– otherother

Program OutlineProgram Outline

Employees and retirees could self-refer Employees and retirees could self-refer to the program or be referred by their to the program or be referred by their physician or other provider physician or other provider

Concerted internal effort to educate and Concerted internal effort to educate and recruit active employees and retirees recruit active employees and retirees into the programinto the program

Program OutlineProgram Outline

Targeting effort to the following groups as much Targeting effort to the following groups as much as possibleas possible

– Retirees and active employees with complex Retirees and active employees with complex drug therapiesdrug therapies

– 4 or more concurrent drugs4 or more concurrent drugs– Multiple physicians and pharmaciesMultiple physicians and pharmacies– Recent hospitalizationRecent hospitalization– More than two chronic illnesses e.g. diabetes More than two chronic illnesses e.g. diabetes

mellitus, COPDmellitus, COPD– High risk drug therapies such as cardiovascular High risk drug therapies such as cardiovascular

drugs, diuretics, non-opioid analgesics, drugs, diuretics, non-opioid analgesics, anticoagulants, and antidiabetic agentsanticoagulants, and antidiabetic agents

Additional Support Additional Support ServiceService

Integration with wellness screeningIntegration with wellness screening– Cholesterol testingCholesterol testing– Diabetes mellitus testingDiabetes mellitus testing– SpirometrySpirometry

Special group classesSpecial group classes– Diabetes educationDiabetes education– Proper inhaler devise use techniquesProper inhaler devise use techniques– Smoking cessationSmoking cessation

MTM Program MetricsMTM Program Metrics

Employee satisfactionEmployee satisfaction

Clinical outcomesClinical outcomes– Reduction in drug therapy problemsReduction in drug therapy problems– Improvement in clinical measuresImprovement in clinical measures

Return on investment and value analysisReturn on investment and value analysis– Direct health care costsDirect health care costs– AbsenteeismAbsenteeism– Presenteeism*Presenteeism*

*The World Health Organization Health and Work Performance Questionnaire (HPQ) *The World Health Organization Health and Work Performance Questionnaire (HPQ) will bewill be

used to assess employee at work performanceused to assess employee at work performance

Financial SupportFinancial Support

Plan would cover MTM Plan would cover MTM service for active service for active employees and retirees employees and retirees for. for.

Promotional programPromotional program

Retiree Cost – Benefit Retiree Cost – Benefit AnalysisAnalysis

Estimated utilizers based on Rx utilization would Estimated utilizers based on Rx utilization would be 64.1% of 1309 members or 839 and 70% be 64.1% of 1309 members or 839 and 70% enrollment (587 members)enrollment (587 members)

Average visits of 4 - 6 per year at a cost of $65 Average visits of 4 - 6 per year at a cost of $65 per visit or $325 per year per enrolleeper visit or $325 per year per enrollee

Estimated clinical visit costs $190,000Estimated clinical visit costs $190,000 Copayment reductions based on 60% generic Copayment reductions based on 60% generic

use and copayments of $5 and $20 and average use and copayments of $5 and $20 and average of 2.5 Rxs/month/retireeof 2.5 Rxs/month/retiree

– 17,610 Rxs at ave copay of $10 would be 17,610 Rxs at ave copay of $10 would be $176,100$176,100

Total cost $366,000Total cost $366,000

Retiree Cost – Benefit Retiree Cost – Benefit AnalysisAnalysis

Blue Cross Blue Shield Cohort Study--Blue Cross Blue Shield Cohort Study--ROI 5 to 1.(Compared total health care ROI 5 to 1.(Compared total health care costs of APCS managed population costs of APCS managed population versus unmanaged.)versus unmanaged.)

Caremark results of 4:1 ROICaremark results of 4:1 ROI Asheville North Carolina ROI of 4:1Asheville North Carolina ROI of 4:1 Minnesota Medicaid results to date = Minnesota Medicaid results to date =

$155 per visit and cost of $72.50$155 per visit and cost of $72.50 Estimated ROI for City program would Estimated ROI for City program would

be estimated at $755 per enrollee or an be estimated at $755 per enrollee or an ROI of about 2.38:1 ROI of about 2.38:1

Organizations Who Have Organizations Who Have Embarked on Similar Embarked on Similar ProgramsPrograms

Minnesota Medicaid programMinnesota Medicaid program City of Asheville NCCity of Asheville NC VF Corporation - Greensboro, NCVF Corporation - Greensboro, NC Mohawk Industries – Dublin, GAMohawk Industries – Dublin, GA Manitowoc Health Care Cooperative – WIManitowoc Health Care Cooperative – WI The Ohio State UniversityThe Ohio State University The Kroger Company – Columbus, OHThe Kroger Company – Columbus, OH The University of KentuckyThe University of Kentucky West Virginia State EmployeesWest Virginia State Employees Blue Ridge PaperBlue Ridge Paper City of ChicagoCity of Chicago