Pharmacy Benefits Uncut

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You may have heard the terms precision medicine, personalized medicine, pharmacogenomics, and molecular medicine used interchangeably. But what do they mean? They all describe a newer approach to preventing and treating diseases that accounts for individual differences in genes, environment, and lifestyle. The goal of precision medicine is to better predict which health inventions will be successful in which patients so that the right treatments can be offered to the right patient at the right time. This contrasts with the conventional approach, which focuses on developing treatments for the average person that may work in some patients but not others.

Where Things Stand Now

Although precision medicine isn’t widely used in healthcare today, pharmacogenomics testing, the aspect of precision medicine that involves identifying how an individual’s genetic makeup affects their response to medications, can help to improve health outcomes and save healthcare dollars. It accounts for the fact that patients with the same condition often respond differently to the same medication. The two disease states in which pharmacogenomics is currently most commonly used are depression and cancer.

As you may know from the experience of your plan members who suffer from depression, many of them end up trying several antidepressants before finding one that’s effective for them. This process puts them at risk of poor health outcomes, non-adherence, and risk of side effects, not to mention increased costs. Pharmacogenomics testing, however, can be used to help select the most appropriate antidepressant for an individual and it’s been shown to improve antidepressant response while reducing costs considerably.

Similarly with cancer drugs, pharmacogenomics testing is used to ensure patients receive the correct drug at the correct dosage and identify which patients are at greatest risk for experiencing adverse events of cancer therapy. Pharmacogenomics testing has been shown to improve outcomes in cancer patients and reduce the incidence of drug-related adverse events. In fact, the absence of pharmacogenomics testing has been linked to over 1300 deaths related to oncology drug toxicities per year.

Other disease states in which pharmacogenomics could be used to optimize drug therapy include HIV, epilepsy, and conditions requiring the use of blood thinners (e.g. stroke, atrial fibrillation).

Pharmacogenomics testing can be done for a specific gene-drug pair to identify how a patient’s genetic makeup could determine their response to a particular drug. Alternatively expanded panel testing can be done to simultaneously test several gene-drug interactions (especially for commonly used medications) so results are available pre-emptively and individual gene-drug tests could be avoided. Samples used for pharmacogenomic testing include blood, saliva, or cells taken from the inside of a patient’s cheek.

Why You Should Offer a Pharmacogenomics Program

As an employer, your ultimate goal is ensuring value for your healthcare dollars. You want your plan members to get the right medication at the right dose and the right time to improve their health and avoid the consequences related to the inefficient, expensive, and frequently detrimental effects of trial-and-error medication selection. Because pharmacogenomics testing can help select the most appropriate medication and dosage for a plan member, as well as identify individuals at highest risk for adverse drug events, it represents a win-win proposition: improving plan member health while simultaneously decreasing costs.

In fact, there's lots of evidence demonstrating the health and economic benefits of pharmacogenomics testing programs. Here’s a quick sampling of the data:

1) A study done in adults aged 40 to 75 years old beginning therapy with the blood thinner warfarin found that individuals who received pharmacogenomics testing had 31% fewer overall hospitalizations compared to those who didn’t undergo pharmacogenomics testing

2) A study of plan members enrolled in a self-insured employer sponsored benefits plan found that pharmacogenomics-enriched comprehensive medication management resulted in significantly fewer inpatient and emergency department visits with estimated overall savings of $128.31 per member per month

3) A study that modeled potential cost savings with pharmacogenomic-guided medication management for patients with depression found it was associated with cost savings of $3962 annually per patient assuming testing costs of $2000.

4 Steps to Implementing a Pharmacogenomics Program

Clearly there's lots of data that a pharmacogenomics testing program can provide benefits for both you and your plan members. If you’re interested in initiating a program, here are the 4 steps you need to take:

1) Educate yourself and your providers. Learn about pharmacogenomics testing by meeting with and requesting detailed information from vendors who provide these services so you’re aware of the various options and what they cost. Also, talk to clinical pharmacists, PBMs, and other employers who’ve implemented programs to learn about the benefits and challenges. Finally, make sure the healthcare providers you work with are aware of pharmacogenomics testing and how to interpret and apply its results. Many of them may be unfamiliar with it since it’s a relatively new intervention in the healthcare space.

2) Decide on coverage. Although it’s likely to be cost saving over the long-term, pharmacogenomics testing itself can be expensive and you need to decide which plan members you’ll provide coverage for. Will it be restricted to high-risk plan members or those diagnosed with certain conditions? Or will coverage be universal, providing all plan members with access to preventive panel testing so that the information is available when needed?

3) Engage plan members. Make sure your plan members are aware they have access to pharmacogenomics testing and they understand its benefits which include identifying the most appropriate medications for them and avoiding unnecessary medication use. Also ensure they know you have processes in place, such as informed consent and restrictions on how information revealed through pharmacogenomics testing will be used, to protect their privacy.

4) Integrate pharmacogenomics with other clinical services. If possible, combine your pharmacogenomics testing program with other clinical programs such as a comprehensive medication management, primary care, or PBM-based clinical programs so all healthcare providers have access to relevant, practical information to optimize your plan members’ medication use.

As an employer, your goal is to ensure your pharmacy benefits plan provides members with timely access to medications that meaningfully improve their health in a way that’s financially sustainable. Including a pharmacogenomics testing program in your plan is an integral strategy to help you achieve this aim.

That’s all for this week.

See you in two weeks,

Nina

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Pharmacy Benefits Uncut is produced by Healthcare Decision Making, a consultancy that helps small and medium sized employers optimize their pharmacy benefits plan. We offer a comprehensive range of services focused on three areas: PBM procurement, ongoing management of your pharmacy benefits plan, and self-policing and oversight of your pharmacy spend. To learn more about how Healthcare Decision Making can help you, email Nina Lathia at nina.lathia@healthcaredecisionmaking.com

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