Healthcare Transformation Learning Session October 22nd Webinar, 1:00 - 2:00 PM Learning Topic: How pharmacists are expanding their roles to improve valuebased healthcare. Featured speakers: • Jim Gartner, Vice President Pharmacy and Medical Management Services, CareSource • Kelli Barnes, Assistant Professor of Clinical Pharmacy, The Ohio State University General Internal Medicine • Emily Vrontos, Specialty Practice Pharmacist, Department of Family Medicine, The Ohio State University Lead Support
Major Support
Additional Support 100% of our Board of Directors & Staff Individual & Corporate Donations
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The expanding role of the pharmacist
Jim Gartner RPh, MBA CareSource 10 28 2014
Why did we want to launch a MTM program? Assist with High Risk members Assist with driving HEDIS results • Improved quality
Appropriate medications Preferred Drug List • Generic alternatives • Reduce interactions • Reduce inappropriate medications
Positively engage pharmacy network
Drive costs savings • Generally see a 2.5-3:1 ROI = MCR
MTM Program Approach • As a part of the MTM program, CareSource members are eligible for a full menu of covered services, which include: 1. Comprehensive Medication Review 2. Prescriber Consultation 3. Patient Adherence Consultation 4. Patient Education & Monitoring
• Members receive MTM coverage through a network of more than 85,000 local pharmacists nationwide, including nearly 3,300 pharmacists in Ohio alone. 4
CareSource Pharmacy Network • Statewide kick-off tour to promote the MTM opportunity within Medicaid – Collaboration with Ohio Colleges of Pharmacy and Ohio Pharmacy Association – Ongoing support from OutcomesMTM Network
Performance team – Team dedicated to providing the necessary support, encouragement and resources pharmacists need to operationalize MTM locally within a community 5
Year-One Results • In the first 12-months of the CareSource MTM program: – Total MTM Services Delivered
106,239
– Consultations provided that helped members avert events such as ER visits, hospitalizations and life-threatening complications2,246
6
Key Activity in Ohio July 1, 2012 – June 30, 2014 Total Patients
122,413
Total Claims
281,209
TIP Claims
35%
Pharmacist Driven Claims
65%
Total Acting MTM Pharmacies
2,420
Estimated Cost Avoidance (AIM) ROI 1.57:1(Year 1)
$57,029,321 $ 3,483,523.63 actual cost savings
Key Activity in Ohio Claim Type CMR
20%
Patient Ed/Monitoring
28%
Adherence
35%
Prescriber Consultation
17%
Prescriber Refusal
7%
Patient refusal
37%
8
Year 2 Results • Analysis is still in works; however, showing similar 4:1 ROI. • Savings are driven by reduction of hospital avoidance – Then ED avoidance
• Drug product cost savings are still being determined. 9
Year 2 Results • CMR before and after review completed – 4500 CMRs reviewed – 12 months utilization before and after Utilization
PMPM Change
RX Cost
Increase 13%
Inpatient Cost
Decrease 6%
Outpatient Cost
Increase 9%
Professional Cost
Decrease 3%
Dental
Increase 1%
ER Rate
Decrease 11% 10
MTM Activities
MTM Stories Medication Adherence and monitoring of BP a concern for member
Pharmacist worked with member to obtain a BP monitor and explained use
Pharmacist explained importance of adherence and provided a pill box and set up weekly check points for member to show pharmacist status of taking medications
MTM Stories Member prescribed multiple medications; two identified as able to be discontinued
Used two medications from same class; NSAIDs
MTM Stories Diabetes medication review • Discussed losing weight • Adherence of medications • Monitoring Blood Sugars
Member was not using Inhaler and Stomach Medication (discontinued)
Member Stories Member with 9 disease states and 20 medications
Incorrectly using maintenance inhaler
Need identified for rescue inhaler Has asthma; shortness of breath
Case Findings • Pharmacists have become health coaches • The CMR conversation leads to greater findings • Pharmacists truly part of the health care team • CareSource members move to the head of the line • Pharmacists are able to practice at a high level of the profession
16
Reimbursement Model • Pharmacies are no longer achieving strong reimbursement for dispensing of RXs • Need to move to service model • Current MTM Model – $10.00 Successful Patient Education and Monitoring – $20.00 Successful Physician Outreach – $75.00 Complete Medication Review – $2.00 for trying
17
Reimbursement Model • Pay for Performance for pharmacists will be an evolution • Achieving success with MTM model will only lead to greater P4P success • Reimbursements – Health Coach – Blood draws – Vaccinations 18
Pharmacist Collaboration to Maximize Value-based Healthcare Kelli Barnes, PharmD, BCACP Emily Vrontos, PharmD, CDE
General Internal Medicine Clinics Martha Morehouse GIM Clinic CarePoint East GIM Clinic Stoneridge GIM Clinic Grandview GIM Clinic Hilliard GIM Clinic Lewis Center Primary Care
National Committee for Quality Assurance (NCQA) tier 3 patientcentered medical homes (PCMH)
Family Medicine Clinics Bethel Road FM Upper Arlington FM CarePoint East FM Rardin FM CarePoint Gahanna FM Worthington FM CarePoint Lewis Center FM New Albany Primary Care National Committee for Quality Assurance (NCQA) tier 3 patient-centered medical homes (PCMH)
Clinic Personnel Attending physicians and residents Pharmacists and pharmacy residents Nurse practitioners Care coordinators (RN) Social workers Medication assistance program coordinator Medical assistants
Disease State Management Population Management Transitional Care Management
GIM Interdisciplinary Diabetes Clinic Patient referred by PCP
Patient interviewed by pharmacist and physician 25
Pharmacist delivers patient education
Physicians follows labs, communicates with PCP
Shared Plan making, goal setting
Pharmacist provides follow-up between visits
Diabetes Clinic Outcomes 10.5%
Hemoglobin A1c
10.0% 9.5% 9.0%
pp<<0.001 0.001
8.5% 8.0% 7.5% Baseline
Most Average Between Readings 333 + 138 days
Rec
Diabetes Clinic Value •
10-14 patients scheduled per clinic (½ day) •
1 Attending physician, 2-3 medical residents, 2 pharmacy residents, 1 pharmacist
•
Billed as 99213 or 99214 visit
•
PCP can focus on other patient needs
•
Interprofessional education
•
Could be modified to pharmacist-only clinic PCP: Primary Care Physician
Family Medicine Diabetes Visits Patient referred by PCP
Appointment scheduled for 1:1 education/ management 28
Labs ordered/ reviewed RPh and PCP
Pharmacist follow-up between PCP visits
Goal setting, medication management
New Service: group visit referral if appropriate
FM Diabetes Visits 5-6 patients scheduled per half day Billed as 99211 Attending physician collaborates for medication recommendations Interprofessional education
Other Disease State Management Offered General Internal Medicine Polypharmacy clinic Anticoagulation clinic Pharmacy appointments
Family Medicine Polypharmacy appointments Multiple medications/disease states Renal/hepatic impairment Adherence Smoking cessation Hypertension/hyperlipidemia education
Shared Disease State Management Population Management Transitional Care Management
Population Management
Population Management: CKD Outcomes Medications Requiring Renal Adjustment N = 270 (14.1%)
Medications Not Requiring Renal Adjustment
N = 132 (48.9%)
N = 1,645 (85.9%)
Medications Renally Adjusted
Medications Not Renally Adjusted
N = 138 (51.1%)
Population Management: CKD Outcomes Before Pharmacist Intervention
N = 132 (48.9%)
N = 138 (51.1%)
After Pharmacist Intervention
N = 222 (82.2%) N = 233 (86.3%)
Medication NOT renally dose adjusted Medication renally dose adjusted
N = 49 (17.8%)
Population Management Opportunities •
Preventative health
•
Chronic disease state management
•
High risk medication monitoring
•
Collaboration with Care Coordinators for identifying patients with diabetes, current smokers
•
Comprehensive medication reviews for CareSource and Ohio State University Health Plan patients
Population Management Value •
Decrease physician time spent during visit
•
PCMH credentialing
•
Improved disease state or preventative health outcomes
•
Potential decrease in adverse drug events
Shared Disease State Management Population Management Transitional Care Management
Transitional Care Management •
99495/99496 introduced in January 2013
•
Contact by “licensed clinical staff” within 2 business days of discharge from acute care setting Type of contact • • •
Phone Email Face-to-face
Acute Care Setting • Acute or rehabilitation hospital • Observation unit • Nursing facility
•
Face to face visit with physician within 7-14 days
•
Continued coordination 30 days post-discharge
•
Reimbursement for physician visit ~50% higher if TCM performed
GIM Transitional Care Management Workflow
GIM Transitional Care Coordination Follow up visit scheduled PRIOR to TCC
Not Scheduled
Follow up visit scheduled After TCC
Scheduled
Scheduled
Not Scheduled
Summary Primary care practice comprised of chronic disease and medication management Pharmacists have unique training to assist in medication management Emerging models provide value/incentive to include pharmacists in PCMH practices
Pharmacist Collaboration to Maximize Value-based Healthcare Kelli Barnes, PharmD, BCACP Emily Vrontos, PharmD, CDE
Healthcare Transformation Learning Session
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• Thank you for joining us today! • Thanks to our speakers! • Thanks to our funding partners!
Sharing lessons learned from implementing best practices in Greater Columbus
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Friday, December 5, 8:00-11:30 AM The Nationwide & Ohio Farm Bureau 4-H Center, 2201 Fred Taylor Dr. Columbus, OH 43210
Lead Support
Major Support
Additional Support 100% of our Board of Directors & Staff Individual & Corporate Donations
www.hcgc.org