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Focusing on Pharmacist-Led Programs to Improve Medication Management Produces Significant Savings
- 1. Focusing on Pharmacist-Led Programs to Improve Medication Management Produces Significant Savings HEIDI YANOSKI WILKES UNIVERSITY PHARM.D, MBA CANDIDATE, 2017 MBA THESIS PRESENTATION
- 2. Objectives Main problem 01 Affordable Care Act (ACA) 02 Transitions of Care (TOC) 03 Medication Therapy Management (MTM) 04 Medication cost- benefit analyses 05 Conclusion 06
- 3. How many medication errors occur annually?
- 4. How many medication errors occur annually? 1.5 MILLION!
- 5. What’s the Problem? 1001 665 328 173 163 124 92 92 62 51 0 200 400 600 800 1000 1200 Healthcare Expenditures in 2016 Cost ($ billion) 32 20 10 5 5 4 3 3 2 2 2016 Market Spread (%) Hospital PCP/Clinical RX Drugs Personal Care Nursing Home Dental Home Health Other Non-Durable Equipment Durable Equipment Healthcare costs and spending have risen dramatically
- 6. What’s the Problem? 50% of Americans suffer from one chronic illness 3.2 billion prescriptions ordered during PCP visits 1.5 million medication errors annually Thirty-day hospital readmissions cost $15 billion
- 7. What’s Been Done? The Affordable Care Act of 2010 Positive influence on the US economy Prominent goal is healthcare spending reduction 30-day readmissions and preventable readmissions reduced
- 8. What Needs to be Done? TOC MTM COST-BENEFIT
- 9. Transitions of Care (TOC) Definition “The movement of patients between health care locations, providers, or different levels of care within the same location as their conditions or care needs change.” Highly-error prone and poorly managed 66% of all medication errors occur during a care transition $3.5 billion annual costs
- 10. TOC Studies Small Mission Hospital, North Carolina 384-patient intervention cohort 9 month study period Savings ROI Medium Kaiser Permanente Colorado Health System Skilled Nursing Facility to home Hospital to home 521 patient experimental group 6 month study period Savings Large State of Hawaii 2083 intervention patients 2 year study period Medication-related hospitalizations Savings ROI
- 11. Total annual savings of three TOC Programs? $10 million.
- 12. Medication Therapy Management Definition “Service or group of services that optimize therapeutic outcomes for individual patients.” Medication errors cause morbidity and mortality $177 billion in additional costs MTM clinics rising in popularity
- 13. MTM Studies Diabetes Geisinger 1875 patients 8 year study Total cost savings Cholesterol Floridian Medicare patients 255 diabetic patients 21 month study Projected savings Long-Term Care North Carolina Long-Term Care Polypharmacy Initiative 5255 members Total savings
- 14. Total amount of savings due to MTM programs? $16.1 MILLION
- 17. Costly Chronic Diseases • 2013 retrospective study • Journal of the American Medical Association (JAMA)
- 19. Cost-Benefit Analysis Definition “A form of economic analysis from a social perspective, in which the costs of medical care are compared with the economic benefits of the care provided, with both the costs and benefits being expressed in monetary units.” Important for payors to determine which drugs should be placed on formulary
- 20. Entresto Cost-Benefit Analysis Entresto (valsartan/sacubitril) PARADIGM Trial projection Added 1 quality life year 3000 avoided hospitalizations annually $27 million saved annually
- 21. Recommendations Savings of all studies examined = $53.1 million annually ACA has shown real benefit Numerous studies in each section proves pharmacist efficacy Continue research to find best way to expand Important step is looking further into insurance companies Already found the savings potential, let’s continue
- 23. References APhA, A. P., & NACDS, N. A. (2008). Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. Retrieved December 3, 2017, from http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf Centers for Disease Control and Prevention. (2017, May 3). Therapeutic Drug Use. Retrieved September 20, 2017, from National Center for Health Statistics: https://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm Centers for Medicare & Medicaid Services. (2016). Evidence Supporting Enhanced Medication Therapy Management. Center for Medicare and Medicaid Innovation. Retrieved November 20, 2017, from https://innovation.cms.gov/Files/x/mtm-evidencebase.pdf Centers for Medicare and Medicaid Services. (2014). Affordable Care Act. Retrieved July 18, 2017, from Medicaid.gov: https://www.medicaid.gov/affordable-care-act/index.html Cost-effectiveness Analysis of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction. (2016, June 22). Journal of the American Medical Association Cardiology. Retrieved July 31, 2017, from file:///C:/Users/Heidi/Downloads/SV%203%20Cost%20Effectiveness%20of%20SacubitrilValsartan%20in%20US.pdf Dieleman, J., Baral, R., Birger, M., & al., e. (2016). US Spending on Personal Health Care and Public Health, 1996-2013. The Journal of the American Medical Association, 316(24), 2627-46. Retrieved July 18, 2017, from http://jamanetwork.com/journals/jama/fullarticle/2594716 Fox, D., Ried, L., Klein, G., Myers, W., & Foli, K. (2009, Mar-Apr). A medication therapy management program's impact on low-density lipoprotein cholesterol goal attainment in Medicare Part D patients with diabetes. Journal of the American Pharmacist's Association, 49(2), 192-9. Retrieved November 20, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/19289345 Gaziano, T. A., Fonarow, G. C., Claggett, B., & al., e. (2016, September). Cost-effectiveness Analysis of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction. Journal of the American Medical Association Cardiology, 1(6), 666-672. Retrieved September 20, 2017, from Cost-effectiveness Analysis of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction Jones, L., Greskovic, G., Grassi, D., & al., e. (2017, September). Medication therapy disease management: Geisinger’s approach to population health management. American Journal of Health-System Pharmacists , 74(18), 1422-1435. Retrieved November 20, 2017, from http://www.ajhp.org/content/74/18/1422
- 24. References, Continued Kim, W. C., & Mauborgne, R. (2004, October). Blue Ocean Strategy. Harvard Business Review, 76-84. Retrieved September 20, 2017, from https://hbr.org/2004/10/blue-ocean-strategy Maeng, D., Yan, X., Graf, T., & Steele Jr., G. (2016, March). Value of Primary Care Diabetes Management: Long-Term Cost Impacts. The American Journal of Managed Care, 22(3), 88-94. Retrieved July 18, 2017, from https://ajmc.s3.amazonaws.com/_media/_pdf/AJMC_03_2016_Maeng%20(final).pdf Manolakis, P. G., & Skelton, J. B. (2010, December 15). Pharmacists' Contributions to Primary Care in the United States Collaborating to Address Unmet Patient Care Needs: The Emerging Role for Pharmacists to Address the Shortage of Primary Care Providers. American Journal of Pharmaceutical Education, 74(10). Retrieved September 20, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058447/ National Committee to Preserve Social Security and Medicare. (2017). Fast Facts About Medicare. Retrieved July 18, 2017, from NCPSSM: http://www.ncpssm.org/Medicare/MedicareFastFacts National Transitions of Care Coalition. (2017). About NTOCC. Retrieved September 20, 2017, from NTOCC.org: http://www.ntocc.org/aboutus.aspx Schoen, C. (2016, February ). The Affordable Care Act and the US Economy: A Five-Year Perspective. The Commonwealth Fund. Retrieved July 18, 2017, from http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/feb/1860_schoen_aca_and_us_economy_v2.pdf?la=en Sen, S., Bowen, J. F., Ganestsky, V. S., & al., e. (2014, September 4). Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings. Pharmacy Practice, 12(3), 508. Retrieved September 20, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4161412/ Trygstad, T., Christensen, D., Wegner, S., SUllivan, R., & Garmise, J. (2009, September 31). Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohort approach using propensity-score matching for both evaluation and targeting. Clinical Therapy, 31(9), 2018-37. Retrieved November 20, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/19843492
Editor's Notes
- Healthcare costs and spending have risen dramatically Hospital care – 32% share with $1.1 trillion spent Physicians and clinical services – 20% with 664.9 billion Prescription drugs – surprisingly only hold only 10% of the market with $328 billion in costs Residential and personal care services – any type of rehabilitation stays or assisted living apartment complexes Nursing home care – Dental Home health – includes rehab at home, wound changing, IV infusion services Other – clinical services provided by independent practitioners such as PT, OT, optometry, podiatry, or chiropractors. Non-durable medical equipment includes eyeglasses, hearing aids, contact lenses, etc. Durable medical equipment includes OTC medications, medical or surgical instruments, dressings, canes, crutches, wheelchairs, etc. The average growth for all these market sectors was 4.22%, with the highest growth in the PCP and Clinical sector at 5.4%, and the lowest, surprisingly, in the pharmaceuticals, which only grew 1.3% in 2016. This was a large change from 2014 and 2015, when the market grew 12.4% and 8.9%, respectively.
- 50% of Americans suffer from one chronic illness 3.2 billion prescriptions ordered during PCP visits 1.5 million medication errors annually Thirty-day hospital readmissions cost $15 billion
- The Affordable Care Act (ACA) accounts for two separate pieces of legislation, the Patent Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, that have been working to expand public health care coverage since it was enacted in March of 2010 Positive influence on the US economy since the 2008 housing bubble recession The US has gained over 14 million new full-time jobs since 2010 5 million more people working now Dramatic decrease on the US unemployment rate, which is 4.1% as of October 2017, compared to October 2009, right before the act was signed into law, at 10% Prominent goal is healthcare spending reduction Incentivized providers to achieve better outcomes at a lower cost 30-day readmission plan, institutions where patients are readmitted after 30 days due to the provision of sub-standard care will not be compensated for their services Early participants in the program achieved savings of $385 million in 2012 and 2013 Medicare admissions for preventable conditions decreased by 25% and 30-day readmission rates fell 17% Placed an emphasis on primary care
- Small Mission Hospital, North Carolina 384-patient intervention cohort 9 month study period Primary endpoint was thirty day readmissions, decreased by 50.2% Results unchanged when adjusted for age, race, gender, and number of disease states Increased validity of study ED admissions also significantly reduced (51%) and sustained at 30, 90, and 365-day period Mean direct cost of a 30-day readmission was $4306 Translated to a $189,464 reductions in utilization at thirty days, and $786,529 annual savings. ROI at 30 days was $12 saved for every $1 invested in pharmacist time, positively sustained through 365 days Medium Kaiser Permanente Colorado Health System has a network of hospitals and skillet nursing facilities, and insurance Two groups in the study Skilled Nursing Facility to home Hospital to home 521 patient experimental group After completing the programs, patients were 78% less likely to die, 29% less likely or need an ER visit, and 17% more likely to follow up with PCP clinicians Savings Average decrease in $9974 in total costs per patient annually Pharmacy utilization costs were significantly increased after enrollment, which was offset by the significant savings in inpatient professional services Annualized cost savings per patient was $5276, which turned out to be $4 million in savings in 2003 Large Conducted throughout the state of Hawaii at 6 different experimental and 5 different control hospitals Looked at 2083 patients over two years ONLY admitted for medication related problems as determined by pre-chosen ICD-9 codes Decreased admissions by 36% Approximately 394 hospitalizations would be avoided annually Amount to an average annual savings of 6.6 million, with a net annual savings of 4.8 million. Pharmacist services cost 1.8 million 264% return on investment
- Diabetes Large initial increase in costs due to patients seeing pharmacists more and being prescribed more medications or more expensive medications Total estimated cost savings associated with any DSC exposure was $47 per member per month and $89 PMPM savings in inpatient costs, (9 pmpm output fees = 2 pmpm in professional fees) which yields approximately $2.8 million in savings annually for 1875 patients – as more patients are enrolled, more savings will be generated. Cholesterol After one year, more than two thirds of these patients reached their cholesterol goals This group, after the 21 months, used less medications to treat their conditions than the control group Florida has approximately 3 million Medicare Part D enrollees, and based on the savings in the study, it would be projected to save $12 million Long-term care Looked at pharmacist-provided MTM services in order to reduce polypharmacy, or drugs used to treat side effects of another medication, or two drugs of the same mechanism. Looked at seniors living in long-term care homes. Cost-savings od $21.63 per member per month in drug cost savings was observed, yielding $1.3 million in savings annually
- JAMA conducted a retrospective study published in 2016 looking at medical claims (government programs, insurance claims, facility surveys, and household surveys) This was in terms of aggregate disease states, in which ischemic heart and cerebrovascular disease (excluding HTN and HLD tx) were the costliest personal healthcare expenditure, accounting for over $231 billion spent from 1996-2013. Diabetes was not far behind.
- This table shows the top ten conditions in which the most personal health care expenditures went towards However, in terms of individual disease, diabetes was number one at 101.4 billion spent Ischemic heart disease was right behind at 88.1 billion spent
- Cardiovascular Entresto (valsartan/sacubitril) Used to treat heart failure PARADIGM Trial projection 3000 avoided hospitalizations annually Added 1 quality life year Savings of $27 million annually