Healthcare Transformation Learning Session

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www.hcgc.org

October 22nd Webinar, 1:00 - 2:00 PM

Learning Topic: How pharmacists are expanding their roles to improve value-based 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

The expanding role of the pharmacist

Jim Gartner RPh, MBACareSource

10 28 2014

Why did we want to launch a MTM program?

Assist with High Risk members

• Improved quality

Assist with driving HEDIS results

Appropriate medications

• Generic alternatives• Reduce interactions• Reduce inappropriate medications

Preferred Drug List

Positively engage pharmacy network

• Generally see a 2.5-3:1 ROI = MCR

Drive costs savings

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.

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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

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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

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Key Activity in Ohio

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) $57,029,321

ROI 1.57:1(Year 1) $ 3,483,523.63 actual cost savings

July 1, 2012 – June 30, 2014

Key Activity in Ohio Claim Type

CMR 20%

Patient Ed/Monitoring 28%

Adherence 35%

Prescriber Consultation 17%

Prescriber Refusal 7%

Patient refusal 37%

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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.

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Year 2 Results• CMR before and after review completed

– 4500 CMRs reviewed– 12 months utilization before and after

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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%

MTM Activities

MTM – CMR intervention after

discharge

Asthmatic patients not on therapy

Children on excessive anti-psychotic RX

Pharmacists in clinic settings

High Risk Case Management referral

MTM StoriesMedication

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 StoriesMember prescribed

multiple medications; two identified as able to

be discontinued

Used two medications from same class; NSAIDs

MTM StoriesDiabetes medication review• Discussed losing weight• Adherence of medications• Monitoring Blood Sugars

Member was not using Inhaler and Stomach

Medication (discontinued)

Member StoriesMember with 9

disease states and 20 medications

Has asthma; shortness of

breath

Incorrectly using maintenance inhaler

Need identified forrescue inhaler

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

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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

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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

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Pharmacist Collaboration to Maximize Value-based Healthcare

Kelli Barnes, PharmD, BCACPEmily Vrontos, PharmD, CDE

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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 patient-centered medical homes (PCMH)

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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)

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Clinic Personnel

Attending physicians and residents Pharmacists and pharmacy residents Nurse practitioners Care coordinators (RN) Social workers Medication assistance program coordinator Medical assistants

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Disease State Management

Population Management

Transitional Care Management

GIM Interdisciplinary Diabetes Clinic

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Patient referred by

PCP

Patient interviewed

by pharmacist and physician

Shared Plan making, goal

setting

Pharmacist provides follow-up

between visits

Pharmacist delivers patient

education

Physicians follows labs,

communicates with PCP

Diabetes Clinic Outcomes

Baseline Most Recent7.5%

8.0%

8.5%

9.0%

9.5%

10.0%

10.5%

p < 0.001

Average Between Readings 333 + 138 days

Hem

oglo

bin

A1c

p < 0.001

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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

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Patient referred by

PCP

Appointment scheduled for 1:1 education/ management

Goal setting, medication

management

New Service: group visit referral if

appropriate

Labs ordered/reviewed RPh

and PCP

Pharmacist follow-up

between PCP visits

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FM Diabetes Visits

5-6 patients scheduled per half day Billed as 99211 Attending physician collaborates for medication

recommendations Interprofessional education

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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

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Shared Disease State Management

Population Management

Transitional Care Management

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Population Management

Identify population

Generate report

Intervention

Track Outcomes Update EMR

CKD managementRenal Medication Dosing

Patients with eGFR < 60 mL/min/1.73m2

Pharmacist InterventionPhysician Collaboration

Laboratory monitoringMedication Dosing

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Population Management: CKD Outcomes

Medications Not Requiring

Renal Adjustment

Medications RequiringRenal Adjustment

N = 270 (14.1%)

MedicationsRenally Adjusted

Medications Not Renally Adjusted

N = 1,645 (85.9%)

N = 138(51.1%)

N = 132 (48.9%)

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N = 138(51.1%)

N = 132 (48.9%)

Population Management: CKD Outcomes

Medication NOT renally dose adjusted

Medication renally dose adjusted

Before Pharmacist Intervention After Pharmacist Intervention

N = 233 (86.3%)

N = 222 (82.2%)

N = 49 (17.8%)

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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

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Population Management Value

• Decrease physician time spent during visit• PCMH credentialing• Improved disease state or preventative health outcomes• Potential decrease in adverse drug events

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Shared Disease State Management

Population Management

Transitional Care Management

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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

• 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

Acute Care Setting• Acute or rehabilitation hospital• Observation unit• Nursing facility

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GIM Transitional Care Management Workflow

Patient Discharged• D

ischarge summary sent to physician

Physician review to determine complexity• M

essage electronically sent to pharmacist

Pharmacist contacts within 2 business days• A

ssess patient; medication reconciliation; confirm appointments; document

Patient follow-up within 7 or 14 days• P

harmacist’s note leads to focused visit

GIM Transitional Care Coordination

Not Scheduled Scheduled

Scheduled

Follow up visit scheduled PRIOR to TCC

Follow up visit scheduled After TCC

NotScheduled

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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, BCACPEmily Vrontos, PharmD, CDE

Healthcare Transformation Learning Session

www.hcgc.org

Send your questions

or reflections

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THANK YOU!

www.hcgc.org

Lead Support Major Support Additional Support

100% of ourBoard of Directors

& Staff

Individual & CorporateDonations

• Thank you for joining us today!

• Thanks to our speakers!

• Thanks to our funding partners!

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Please save the date for our last learning session of 2014!

Sharing lessons learned from implementing best practices in Greater Columbus

Friday, December 5, 8:00-11:30 AM

The Nationwide & Ohio Farm Bureau 4-H Center, 2201 Fred Taylor Dr. Columbus, OH 43210