Beyond Disease Management

Beyond Disease Beyond Disease ManagementManagement

An Introduction to An Introduction to Medication Therapy Medication Therapy

ManagementManagementServicesServices

Why Do We Even Care?Why Do We Even Care? Over 100 million Americans suffer from one Over 100 million Americans suffer from one

or more chronic illnesses and 40 million are or more chronic illnesses and 40 million are limited by themlimited by them

Despite annual spending of nearly $1 trillion Despite annual spending of nearly $1 trillion & significant advances in care, one-half or & significant advances in care, one-half or more patients still don’t receive appropriate more patients still don’t receive appropriate carecare

Gaps in quality care lead to more than 57,000 Gaps in quality care lead to more than 57,000 avoidable deaths per yearavoidable deaths per year

Better use of best practice medical care could Better use of best practice medical care could avoid nearly 41 million sick days and more avoid nearly 41 million sick days and more than $11 billion annually in lost productivitythan $11 billion annually in lost productivity

Patients and families increasingly recognize Patients and families increasingly recognize the defects in their carethe defects in their care

Source: www.improvingchroniccare.org/change/model/modeltalk.html

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

ConditionCondition Average Number of Unproductive Average Number of Unproductive Hours in a Typical 8-Hour Work Hours in a Typical 8-Hour Work

DayDay

Heart DiseaseHeart Disease 4.34.3

Respiratory InfectionRespiratory Infection 4.14.1

DiabetesDiabetes 4.04.0

MigraineMigraine 3.43.4

High Blood PressureHigh Blood Pressure 3.43.4

ArthritisArthritis 3.23.2

AllergiesAllergies 2.82.8

High StressHigh Stress 2.32.3

Anxiety Anxiety 2.22.2

DepressionDepression 2.22.2

Why Do We Even Care?Why Do We Even Care? 15-24% of hypertensives are controlled15-24% of hypertensives are controlled 42% of diabetics have controlled lipid 42% of diabetics have controlled lipid

levelslevels 35% of eligible patients with atrial 35% of eligible patients with atrial

fibrilation receive anticoagulationfibrilation receive anticoagulation 25% of people with depression are 25% of people with depression are

receiving adequate treatmentreceiving adequate treatment 44% of discharged CHF patients are 44% of discharged CHF patients are

readmitted within 120 daysreadmitted within 120 daysSource: www.improvingchroniccare.org/change/model/modeltalk.html

Why is This?Why is This?

Systems are perfectly

designed to obtain the

results they achieve

How Can It Be Fixed?How Can It Be Fixed?

IOM Quality ReportIOM Quality Report ““The current care systems cannot do the The current care systems cannot do the

job.”job.” ““Trying harder will not work.”Trying harder will not work.” ““Changing care systems will.”Changing care systems will.”

Conclusion: We must transition the Conclusion: We must transition the current healthcare system from one current healthcare system from one focused on “crisis management” to one focused on “crisis management” to one focused on the big picture.focused on the big picture.

Disease Management Disease Management ComponentsComponents

Population identification processes; Population identification processes; Evidence-based practice guidelines; Evidence-based practice guidelines; Collaborative practice models to include physician Collaborative practice models to include physician

and support-service providers; and support-service providers; Patient self-management education (may include Patient self-management education (may include

primary prevention, behavior modification primary prevention, behavior modification programs, and compliance/surveillance); programs, and compliance/surveillance);

Process and outcomes measurement, evaluation, and Process and outcomes measurement, evaluation, and management; management;

Routine reporting/feedback loop (may include Routine reporting/feedback loop (may include communication with patient, physician, health plan communication with patient, physician, health plan and ancillary providers, and practice profiling). and ancillary providers, and practice profiling).

* Note: Full-service disease management programs must * Note: Full-service disease management programs must include all six components. Programs consisting of include all six components. Programs consisting of fewer components are disease management support fewer components are disease management support services.services.

Source: Disease Management Association of America (www.dmaa.org)

Many initiatives now moving away Many initiatives now moving away from “disease management”from “disease management” Phrase dehumanizes the patientPhrase dehumanizes the patient

Focus should be on taking care of the Focus should be on taking care of the patient, not a disease that they possesspatient, not a disease that they possess

Wellness programsWellness programs Don’t just focus on the patient, but the Don’t just focus on the patient, but the

whole patientwhole patient

Beyond Disease Beyond Disease ManagementManagement

Number of Chronic Number of Chronic Conditions per Medicare Conditions per Medicare

BeneficiaryBeneficiaryNumber ofNumber of Percent ofPercent of Percent ofPercent of

ConditionsConditions BeneficiariesBeneficiariesExpendituresExpenditures

00 1818 11

11 1919 44

22 2121 1111

33 1818 1818

44 1212 2121

55 77 1818

66 33 1313

7+7+ 22 1414

63%

95%


The Chronic Care ModelThe Chronic Care Model Model development began in 1993Model development began in 1993 Developed from Developed from

Extensive literature review Extensive literature review Information obtained via intensive Information obtained via intensive

interviews with 72 “best practices”interviews with 72 “best practices” Input from an 40 member advisory Input from an 40 member advisory

committeecommittee Model applied with diabetes, Model applied with diabetes,

depression, asthma, CHF, CVD arthritis, depression, asthma, CHF, CVD arthritis, AIDS, preventive care and geriatricsAIDS, preventive care and geriatrics

The Chronic Care ModelThe Chronic Care Model Initially, researched diabetes management Initially, researched diabetes management

programs and found that intervention types fall programs and found that intervention types fall into four general domains:into four general domains: Decision supportDecision support Clinical Information systemsClinical Information systems Self-management supportSelf-management support Delivery system designDelivery system design

Generally, the more of these domains a Generally, the more of these domains a program contains, the better the resultsprogram contains, the better the results

Subsequent reviews of programs dealing with Subsequent reviews of programs dealing with other conditions reinforced these elements and other conditions reinforced these elements and additionally highlighted the importance of additionally highlighted the importance of planned encountersplanned encounters and better use of and better use of non-non-physician teamphysician team members in facilitating members in facilitating delivery system designdelivery system design


The Promise of The Promise of Team-Based MedicineTeam-Based Medicine

The The team team approach is really our only approach is really our only hope for sustaining our healthcare hope for sustaining our healthcare system into the future due to factors* system into the future due to factors* including:including: Expanding pace and scope of discovery in Expanding pace and scope of discovery in

medical science and technologymedical science and technology The growing complexity of medical careThe growing complexity of medical care Increasing number of Americans with Increasing number of Americans with

chronic illnesses (and their changing chronic illnesses (and their changing expectations)expectations)

Resource constraintsResource constraints*From Chaos to Care: The Promise of Team-Based Medicine. David Lawrence, MD. Chairman

Emeritus, Kaiser Permanente

Source: www.improvingchroniccare.org

The Chronic Care ModelThe Chronic Care Model Clinical Information Systems Clinical Information Systems - Organize - Organize

patient and population data to facilitate patient and population data to facilitate efficient and effective careefficient and effective care Identify relevant subpopulations for proactive Identify relevant subpopulations for proactive

carecare Provide timely reminders for providers and Provide timely reminders for providers and

patientspatients Facilitate individual patient care planningFacilitate individual patient care planning Share information with patients and providers Share information with patients and providers

to coordinate care to coordinate care (2003 refinement)(2003 refinement) Monitor performance of practice team and care Monitor performance of practice team and care

system system


Good

Fair

Poor

Good

Fair

Poor

The Chronic Care ModelThe 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


Good

Fair

Poor

The Chronic Care ModelThe Chronic Care Model Delivery system designDelivery 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

Good

Fair

Poor

The Chronic Care ModelThe Chronic Care Model Self management supportSelf management support - Empower - Empower

and prepare patients to manage their and prepare patients to manage their health and health carehealth and health care Emphasize the patient’s central role in Emphasize the patient’s central role in

managing their healthmanaging their health Use effective self-management support Use effective self-management support

strategies that include assessment, goal-strategies that include assessment, goal-setting, action planning, problem-solving setting, action planning, problem-solving and follow-upand follow-up

Organize internal and community resources Organize internal and community resources to provide ongoing self-management to provide ongoing self-management support to patients support to patients Source:

www.improvingchroniccare.org

Good

Fair

Poor

Why Do Pharmacists Need Why Do Pharmacists Need to be on the Healthcare to be on the Healthcare

Team?Team? 80/20 rule – 20% of the patients are 80/20 rule – 20% of the patients are

responsible for 80% of the costsresponsible for 80% of the costs Who are the “20 percenters”? Patients Who are the “20 percenters”? Patients

with:with: Diabetes?Diabetes? Heart Disease?Heart Disease? Cancer?Cancer? And now… a “New Disease”And now… a “New Disease”

The “New Disease”The “New Disease”

Yearly costs in excess of $177 billion Yearly costs in excess of $177 billion (1999)(1999)

5th leading cause of death in the US 5th leading cause of death in the US Behind heart disease, cancer, stroke and Behind heart disease, cancer, stroke and

respiratory diseaserespiratory disease Attributable to more deaths than diabetes, Attributable to more deaths than diabetes,

Alzheimer's, kidney disease, breast cancer and Alzheimer's, kidney disease, breast cancer and AIDS AIDS

Highly preventableHighly preventable

What’s the “disease”?What’s the “disease”?

Adverse Drug ReactionsAdverse Drug Reactions Many of the medications that we take Many of the medications that we take

actually end up causing more problems than actually end up causing more problems than they solve because they are not prescribed, they solve because they are not prescribed, used, or monitored appropriatelyused, or monitored appropriately

We actually spend We actually spend moremore money in the US money in the US dealing with the problems that medications dealing with the problems that medications cause than we spend on the medications cause than we spend on the medications themselvesthemselves

The New “Disease”?The New “Disease”?

Contributing FactorsContributing Factors

Increases in:Increases in: Numbers of people with chronic Numbers of people with chronic

conditions (asthma, allergies, diabetes, conditions (asthma, allergies, diabetes, hypertension, hyperlipidemia, etc.)hypertension, hyperlipidemia, etc.)

Numbers of treatment optionsNumbers of treatment options False sense of securityFalse sense of security Demands on physician time Demands on physician time

Reinforcing a “crisis management Reinforcing a “crisis management healthcare system”healthcare system”

A New Kind of “High-Risk” A New Kind of “High-Risk” (& High-Cost) Individual(& High-Cost) Individual

NOT someone with a specific diseaseNOT someone with a specific disease NOT someone on a specific medicationNOT someone on a specific medication Someone who takes Someone who takes multiple medicationsmultiple medications

and has and has multiple chronic conditionsmultiple chronic conditions – – Predisposed to:Predisposed to: Multiple providers Fragmented careMultiple providers Fragmented care Interactions – Drug/drug, drug/disease, drug/ageInteractions – Drug/drug, drug/disease, drug/age Inappropriate/unnecessary prescriptionsInappropriate/unnecessary prescriptions Inadequate monitoring for efficacy and toxicityInadequate monitoring for efficacy and toxicity Non-compliance/inappropriate useNon-compliance/inappropriate use Suboptimal outcomesSuboptimal outcomes

Pharmacists: An Untapped Pharmacists: An Untapped ResourceResource

All these individuals have a common All these individuals have a common root problem:root problem: Inadequate oversight/monitoring of Inadequate oversight/monitoring of

complex drug regimens consisting of complex drug regimens consisting of multiple medications that have the potential multiple medications that have the potential to adversely effect each other’s actions as to adversely effect each other’s actions as well as the individual’s chronic conditionswell as the individual’s chronic conditions

Who better to deal with these situations Who better to deal with these situations than a pharmacist?than a pharmacist?


Pharmacists receive more training on the Pharmacists receive more training on the safe, effective and appropriate use of safe, effective and appropriate use of medications than any other healthcare medications than any other healthcare professionalprofessional

The only pharmacy degree offered in the The only pharmacy degree offered in the United States is the Doctor of Pharmacy United States is the Doctor of Pharmacy or PharmDor PharmD

Pharmacists are the most accessible Pharmacists are the most accessible healthcare provider, yet few individuals healthcare provider, yet few individuals ever have meaningful interactions with a ever have meaningful interactions with a pharmacist…Why?pharmacist…Why?

Why is This?Why is This?

Systems are perfectly

designed to obtain the

results they achieve


““Closed” healthcare systems like Kaiser and Closed” healthcare systems like Kaiser and the VA have had great success integrating the VA have had great success integrating pharmacists into the healthcare teampharmacists into the healthcare team

Virtually all other health plans and PBMs Virtually all other health plans and PBMs view pharmacists as someone who view pharmacists as someone who facilitates drug distributionfacilitates drug distribution Pharmacists cannot get paid out of the medical Pharmacists cannot get paid out of the medical

benefitbenefit Pharmacies only get paid if an Rx goes out the Pharmacies only get paid if an Rx goes out the

doordoor

Strategies for Delivering Strategies for Delivering MTMMTM

Two basic types of Medication Therapy Two basic types of Medication Therapy Management (MTM) ServicesManagement (MTM) Services Dispensing-relatedDispensing-related: Brief therapy-specific : Brief therapy-specific

interventions designed to take advantage of interventions designed to take advantage of the pharmacist’s unparalleled patient accessthe pharmacist’s unparalleled patient access

Non-dispensing relatedNon-dispensing related: More time-: More time-intensive encounters that leverage the intensive encounters that leverage the pharmacist’s unique expertise in reviewing pharmacist’s unique expertise in reviewing complex drug regimens to assess for complex drug regimens to assess for appropriateness; monitor for efficacy, adverse appropriateness; monitor for efficacy, adverse reactions and drug interactions; promote reactions and drug interactions; promote compliance and appropriate use, etc.compliance and appropriate use, etc.

Dispensing Related Dispensing Related MTMS MTMS

Pharmacist is responsible for Pharmacist is responsible for identifying which patients need what identifying which patients need what servicesservices Realign the financial incentives at the Realign the financial incentives at the

pharmacy to promote safe, effective and pharmacy to promote safe, effective and appropriate medication use rather than appropriate medication use rather than simply fast, cheap and accurate simply fast, cheap and accurate dispensing.dispensing.

ProPro – Reach a – Reach a large population of large population of individuals.individuals.

ConCon – Counter to how – Counter to how pharmacy payment systems pharmacy payment systems are set up. are set up.

Difficult for to target Difficult for to target services specifically to services specifically to individuals w/greatest needindividuals w/greatest need

Example :Example :

A patient presented to a pharmacyA patient presented to a pharmacy with two with two new prescriptions for the same diabetes new prescriptions for the same diabetes medication. The pharmacistmedication. The pharmacist noted that the two noted that the two prescriptions used together would likely result prescriptions used together would likely result in an overdose. The pharmacist contacted the in an overdose. The pharmacist contacted the doctor to clarify the dosing regimen. The doctor to clarify the dosing regimen. The physician had intended for the patient to use physician had intended for the patient to use one prescription during the first month and the one prescription during the first month and the other prescription as a dose increase for the other prescription as a dose increase for the second month. The pharmacist educated the second month. The pharmacist educated the patient according to the doctor’s instructions patient according to the doctor’s instructions and averted a potentially life-threatening and averted a potentially life-threatening situation. situation.

Dispensing Related Dispensing Related MTMS MTMS

NON-Dispensing Related NON-Dispensing Related MTMSMTMS

More intensive services for patients who are high-More intensive services for patients who are high-riskrisk

Services are arranged by appointment (not at the Services are arranged by appointment (not at the pharmacy counter…not even necessarily in the pharmacy counter…not even necessarily in the pharmacy) pharmacy)

Pharmacists review patient’s profile, meet with Pharmacists review patient’s profile, meet with patient (preferably in person), identify and patient (preferably in person), identify and address barriers to appropriate, cost-effective careaddress barriers to appropriate, cost-effective care

Recommendations sent to patient’s healthcare Recommendations sent to patient’s healthcare team for consideration and action as team for consideration and action as appropriate/necessaryappropriate/necessary

ProPro – Direct applicability – Direct applicability to chronic care model. to chronic care model. Ability for push vs. pullAbility for push vs. pull

ConCon – Model needs – Model needs development and development and supportsupport

NON-Dispensing Related NON-Dispensing Related MTMSMTMS

Example:Example: A Pharmacist conducts a Comprehensive A Pharmacist conducts a Comprehensive

Medication Review for a patient taking Medication Review for a patient taking multiple medications. During the review the multiple medications. During the review the pharmacist found the patient was taking pharmacist found the patient was taking seven prescription drugs along with twelve seven prescription drugs along with twelve over-the-counter products. In reviewing over-the-counter products. In reviewing these medications, the pharmacist identified these medications, the pharmacist identified and resolved nine drug therapy and resolved nine drug therapy complications of various severities – complications of various severities – including three to lower drug costs and one including three to lower drug costs and one which potentially averted an ER visit. which potentially averted an ER visit.

Hybrid ModelHybrid ModelSemi-Dispensing Related Semi-Dispensing Related

MTMSMTMS Someone else (payer, PBM, plan, etc) Someone else (payer, PBM, plan, etc)

identifies which specific patients are identifies which specific patients are in need of certain medication-related in need of certain medication-related interventions and refers them to the interventions and refers them to the patient’s pharmacy for executionpatient’s pharmacy for execution

ProPro – Leverages – Leverages existing local existing local relationships between relationships between pharmacists and their pharmacists and their patients & other patients & other providersproviders

ConCon – Questionable – Questionable compatibility with compatibility with current community current community pharmacy business pharmacy business modelmodel

Example :Example :

A PBM mines their pharmacy claims data and identifies A PBM mines their pharmacy claims data and identifies a patient who appears to be non-compliant with their a patient who appears to be non-compliant with their Coumadin therapy. The pharmacy where the patient Coumadin therapy. The pharmacy where the patient obtained the medication in question is told that they obtained the medication in question is told that they should have a pharmacist contact the patient and should have a pharmacist contact the patient and investigate the potential compliance problem. The investigate the potential compliance problem. The pharmacist calls the patient and finds out that he often pharmacist calls the patient and finds out that he often forgets to take his medication in the morning. After forgets to take his medication in the morning. After some discussion, the pharmacist identifies that the first some discussion, the pharmacist identifies that the first thing the patient does every morning is make a pot of thing the patient does every morning is make a pot of coffee. The pharmacist recommends that the patient coffee. The pharmacist recommends that the patient keep their bottle of Coumadin by the coffee pot and keep their bottle of Coumadin by the coffee pot and commit to not making coffee until their medication is commit to not making coffee until their medication is taken. Patient agrees and doesn’t miss another dose. taken. Patient agrees and doesn’t miss another dose. Pharmacist documents intervention, submits claim to Pharmacist documents intervention, submits claim to PBM which pays the pharmacy $20 for the intervention.PBM which pays the pharmacy $20 for the intervention.

Semi-Dispensing Related Semi-Dispensing Related MTMSMTMS

Evidence of ValueEvidence of Value Dispensing-related MTMS Dispensing-related MTMS

Florida MedicaidFlorida Medicaid Community Pharmacist Identification and Community Pharmacist Identification and

management of Quality Related Events management of Quality Related Events (QREs)(QREs)

Average estimated costs avoided per dollar Average estimated costs avoided per dollar paid: $15.57paid: $15.57

Non-Dispensing related MTMSNon-Dispensing related MTMS Iowa Medicaid - Pharmaceutical Case Iowa Medicaid - Pharmaceutical Case

Management Program Management Program Pharmacists and physicians make MTM Pharmacists and physicians make MTM

appointments with high risk patientsappointments with high risk patients Significant improvements in medication Significant improvements in medication

safety without any increases in overall safety without any increases in overall healthcare costshealthcare costs

Evidence of ValueEvidence of Value Wyoming PharmAssist ProgramWyoming PharmAssist Program

Residents who have concerns about Residents who have concerns about their meds are scheduled a one-on-one their meds are scheduled a one-on-one visit with a pharmacist who look for visit with a pharmacist who look for potential interactions, duplications, cost potential interactions, duplications, cost savings opportunities, etc. savings opportunities, etc.

Patients saved an average of $155 per Patients saved an average of $155 per monthmonth

Asheville ProjectAsheville Project

The Asheville Project…The Asheville Project…In the BeginningIn the Beginning

Initial point of discussion in 1994 was a Initial point of discussion in 1994 was a diversionary tactic to get hospital and community diversionary tactic to get hospital and community pharmacists to stop fighting over discriminatory pharmacists to stop fighting over discriminatory pricingpricing

““Partnering” with hospital system, PBM, NCAP, Partnering” with hospital system, PBM, NCAP, NCCPC, UNC & Campbell Schools of Pharmacy NCCPC, UNC & Campbell Schools of Pharmacy

Invitation to all pharmacists in community in 1996Invitation to all pharmacists in community in 1996 Responses of independents vs. chainsResponses of independents vs. chains Two weekends (32 hours) of training by physicians Two weekends (32 hours) of training by physicians

and diabetes educatorsand diabetes educators Compensation Compensation afterafter results results

Patient Incentives and Patient Incentives and Care ModelCare Model

Patient recruitment in 1997Patient recruitment in 1997 IncentivesIncentives

Glucose metersGlucose meters PBM co-pay waiversPBM co-pay waivers Labs without co-paysLabs without co-pays

MD Collaboration & “buy in”MD Collaboration & “buy in” Patient education & community resources Patient education & community resources

— Mission + St. Joseph’s Diabetes Center— Mission + St. Joseph’s Diabetes Center Matching patients to pharmacists for Matching patients to pharmacists for

Medication Therapy and Case Medication Therapy and Case ManagementManagement

Direct Medical Costs in Direct Medical Costs in The Asheville ProjectThe 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 Patient Behaviors Over Time in Time in

The Asheville ProjectThe Asheville Project

The “Asheville Project” The “Asheville Project” TodayToday

Program began in 1997 with 49 people with Program began in 1997 with 49 people with diabetics employed by the City of Asheville diabetics employed by the City of Asheville working with community RPh’s, the Diabetes working with community RPh’s, the Diabetes Education Center and physiciansEducation Center and physicians

Now over 1800 patients from 10 employers are Now over 1800 patients from 10 employers are enrolled for diabetes, asthma, hypertension enrolled for diabetes, asthma, hypertension and lipid therapy management and depressionand lipid therapy management and depression

50% reduction in sick days in the first year50% reduction in sick days in the first year Employers have saved over $5,000,000 dollars Employers have saved over $5,000,000 dollars

in health care costs in health care costs Now several pharmacists do this as their job Now several pharmacists do this as their job

and there are pharmacy residents for the and there are pharmacy residents for the program in addition to community pharmacistsprogram in addition to community pharmacists

ConclusionsConclusions Follow the dollars and you’ll never get lostFollow the dollars and you’ll never get lost Ask prospective vendors if/how they employ Ask prospective vendors if/how they employ

the 4 critical components:the 4 critical components: Clinical Information systemsClinical Information systems Decision supportDecision support Delivery system designDelivery system design Self-management supportSelf-management support

Place critical importance onPlace critical importance on Strategies aimed at utilizing existing providers Strategies aimed at utilizing existing providers

and relationships through promotion of practice and relationships through promotion of practice changechange

Ability to use team-based care & community Ability to use team-based care & community resourcesresources

Questions?Questions?

Documents

Beyond Disease Management