Beyond Disease Management

1. Beyond Disease Management An Introduction to Medication Therapy ManagementServices

2. Why Do We Even Care? • 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, half or more of 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

3. Why Do We Even Care? Average Number of Unproductive Hours by Condition*

4. Why Do We Even Care? • 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

5. Why is This? Systems are perfectly designed to obtain the results they achieve

6. How Can It Be Fixed? • Institue of Medicine Quality Report • “The current care systems cannot do the job” • “Trying harder will not work” • “Changing care systems will” • Conclusion: We must transition the current healthcare system from one focused on “crisis management” to one focused on the big picture

7. Disease Management Components • Population identification processes; • Evidence-based practice guidelines; • Collaborative practice models to include physician and support-service 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. Source: Disease Management Association of America (www.dmaa.org)

8. Beyond Disease Management • Many initiatives now moving away from “disease management” • Phrase dehumanizes the patient • Focus should be on taking care of the patient, not a disease that they possess • Wellness programs • Don’t just focus on the patient, but the whole patient

9. Number of Chronic Conditions per Medicare Beneficiary Number of Percent of Percent of Conditions Beneficiaries Expenditures 0 18 1 1 19 4 2 21 11 3 18 18 4 12 21 5 7 18 6 3 13 7+ 2 14 95% 63% Source: www.improvingchroniccare.org/change/model/modeltalk.html

10. The Chronic Care Model • 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 • Model applied with diabetes, depression, asthma, CHF, CVD arthritis, AIDS, preventive care and geriatrics

11. The Chronic Care Model • Initially, researched diabetes management programs and found that intervention types fall into four general domains: • 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

12. The Promise of Team-Based Medicine • 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 *From Chaos to Care: The Promise of Team-Based Medicine. David Lawrence, MD. Chairman Emeritus, Kaiser Permanente

13. Source: www.improvingchroniccare.org

14. The Chronic Care Model • 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 Source: www.improvingchroniccare.org

15. Poor Fair Good

16. Poor Fair Good

17. The Chronic Care Model • 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 Source: www.improvingchroniccare.org

18. Poor Fair Good

19. The Chronic Care Model • Delivery system design- Assure the delivery of effective, efficient clinical care and self-management 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) Source: www.improvingchroniccare.org

20. Poor Fair Good

21. The Chronic Care Model • 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 Source: www.improvingchroniccare.org

22. Poor Fair Good

23. Why Do Pharmacists Need to be on the Healthcare Team? • 80/20 rule – 20% of the patients are responsible for 80% of the costs • Who are the “20 percenters”? Patients with: • Diabetes? • Heart Disease? • Cancer? • And now… a “New Disease”

24. The “New Disease” • 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 • Highly preventable What’s the “disease”?

25. The New “Disease”? • Adverse Drug Reactions • 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 • We actually spend more money in the US dealing with the problems that medications cause than we spend on the medications themselves

26. Contributing Factors • 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”

27. A New Kind of “High-Risk” (& High-Cost) Individual • NOT someone with a specific disease • NOT someone on a specific medication • Someone who takes multiple medications and has multiple chronic conditions – Predisposed to: • 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

28. Pharmacists: An Untapped Resource • All these individuals have a common root problem: • 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?

29. Pharmacists: An Untapped Resource • 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?

30. Why is This? Systems are perfectly designed to obtain the results they achieve

31. Pharmacists: An Untapped Resource • “Closed” healthcare systems like Kaiser and the VA have had great success integrating pharmacists into the healthcare team • 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

32. Strategies for Delivering MTM • 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.

33. Dispensing Related MTMS • 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 pharmacy payment systems are set up Difficult for to target services specifically to individuals w/greatest need Pro – Reach a large population of individuals

34. Dispensing Related MTMS • Example : A patient presented to a pharmacywith two new prescriptions for the same diabetes medication. The pharmacistnoted 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.

35. NON-Dispensing Related MTMS • 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

36. NON-Dispensing Related MTMS • 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.

37. Hybrid ModelSemi-Dispensing Related MTMS • 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

38. Semi-Dispensing Related MTMS • 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.

39. Evidence of Value • Dispensing-related MTMS • 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 • 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

40. 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

41. The Asheville Project…In the Beginning • 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

42. Patient Incentives and Care Model • 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

43. 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

44. Patient Behaviors Over Time in The Asheville Project

45. The “Asheville Project” Today • Program began in 1997 with 49 people with diabetes 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

46. Conclusions • 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 • 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

47. Questions?