Pharmacogenetics in Practice: What Works When Implementing PGx? [Podcast]

11 Aug Pharmacogenetics in Practice: What Works When Implementing PGx? [Podcast]

Introducing pharmacogenetics to a group of people, a population if you will, can be tricky, but maintaining focus on patient experience, outcomes, and wellbeing can help.

In this episode of the Precision Insights podcast, Curt Dame, VP of Health Solutions at Aon, explains his experience with implementing pharmacogenetics (PGx) into health plans.

Let’s get started. 

Table of contents

• How did you come up with the idea of introducing pharmacogenetics as part of a population health management strategy?
• How do you actually implement pharmacogenomics? How do you do it on the ground?
• How did the team engage and communicate with members about this pilot project?
• The project has been going on for over two years now, are there any new results you would like to share with the listeners? 
• The results are impressive! What are some barriers or challenges you’ve seen around the adoption of pharmacogenomics at the point of care?
• How long does it take for a pharmacist to do a medication action plan?

How did you come up with the idea of introducing pharmacogenetics as part of a population health management strategy?

We started this personalized medicine project right around 2014. I was managing several university clients’ health plans. What we do when we consult for health plans is look at their population health management programs. The metrics that we try to manage within a health plan are chronic disease state, medications, and medication adherence. Key metrics like that are crucial to how we look at chronic disease and how we manage that chronic disease state. 

One of the universities that I worked with has an incubator program. Through that incubator program, I was introduced to a company that was working in the pharmacogenomics space and they took the time to educate me about the actual science of pharmacogenomics. 

The science sounded so powerful, and given I had some very significant clients that I was helping in regard to their health plan, health spend, engagement and population health management, I thought I could be an agent for change. They asked me, “Curt, if this is the science that we have, how would you elevate this program? And could you use it with your clients?”

PGx and Population health management: An innovative project

Through a process of learning and talking to the scientists at this pharmacogenomics company and external research, I quickly realized that the science was solid. If the results are what we think they are, every self-funded plan that we work with should have some type of pharmacogenomics program. Taking that one step further, this should become a standard of care in the medical field.

I’ve been blessed with a client, Teachers’ Retirement System of Kentucky (TRS), that is very member-centric. They put the member and the quality outcomes before price and expense.

Obviously, we have to be concerned about the cost of medical care, but having a client that is willing to jump in the deep end and look at some cutting-edge tools that might help improve their members’ quality of care, quality of life, and enable better health outcomes, is something that you just don’t find that very often. 

I, along with the pharmacogenomics scientists, traveled to the Teachers’ Retirement System of Kentucky. We gave them a presentation, and almost immediately they bought in. That’s a long way around to tell you how I got into the pharmacogenomics industry. 

How do you actually implement pharmacogenomics? How do you do it on the ground?

This is a very unique relationship in Kentucky. We are driven by a couple of the universities that I worked with. Through one of the universities, we actually developed what’s known as the KnowYourRX coalition, a coalition for prescription drugs, and more specifically, the purchasing of prescription drugs. But it’s not just a purchasing coalition. The idea of building this coalition was to bring better quality care to the members through medication therapy management. It just so happened that when we found this coalition, the majority of the initial members were my clients.

PGx and Pharmacists: Bridging the gap for successful implementation 

The unique thing about the coalition is that pharmacists are embedded in it. The pharmacists service every member and provide medication therapy management to them. They help control costs through the plans, but they also look at the drug regimens that members are on and help manage them. 

KnowYourRX coalition had been in place with the Teachers Retirement System for about five years prior to the pharmacogenomics program. We know that there was already an established relationship.  The KnowYourRX pharmacists can work with both the member and the physician to determine if a change in medication is required. We also know that it’s not just about the pharmacogenomics results. It’s important to consider gene-to-drug interaction, drug-to-drug interaction, and also the lifestyle factors that can all be very important in whether a drug is metabolized properly.

(Related Post: How Can Pharmacogenetics Be Helpful To Doctors?) 

Medication therapy management: Integrating PGx to optimize medications 

When the pharmacist gets the results from the gene panel, they call the member. They not only talk to the member about the results of their test, but they also ask critical questions to find out what other lifestyle factors (i.e. grapefruit juice) might impact the medications that they’re taking, and what other non-prescribed medication they are taking. They pull all of this information into a medication action plan (M.A.P.). It can then be utilized as a report to provide to the physician, and an explanation is given to the physician if a drug needed to be changed from the results of the medication action plan.

How did the team engage and communicate with members about this pilot project?

I will say that the Teachers’ Retirement System has a great team. Certainly, the marketing to the members was very important. The Teacher’s Retirement System was concerned that members would have more worries about data privacy.

All the protections were in place, but the marketing that addressed privacy concerns was key. The marketing of the program in general was a multi-pronged approach, which includes group meetings and monthly newsletters. All of those efforts combined to help engage the member in an impactful way.

It became an exciting project for the members to participate in. We also did a focus group prior to sending any information to the teachers. Through the focus groups, we learned a little bit about what methods of communication work. There were several phases of sending letters of participation out to the members.  

The project has been going on for a little over two years now, are there any new results you would like to share with the listeners? 

It is an ongoing project. We are in the third year of the project, and I’ll give you some metrics as of January 2020. 

First, I’d like to give you a little more information about the Teachers’ Retirement System of Kentucky. They have about 36,000 members. The goal was to engage with all 36,000 members. From a risk profile we ran early on, we learned that the members are taking 15 medications each on average. We had about 75% of members with high blood pressure, 58% on high cholesterol medication, 50% on some type of pain and inflammatory medications. We knew that 83% of the population was taking a medicine that had some type of known pharmacogenomics implication. The population has an average age of 74, which is considered a retiree population, so we knew that there was significant risk there.

With those numbers in mind, we currently have enrolled about 8,500 members. We have approximately 7,000 members that have gone through the full gene panel, have received the results, and have received medication therapy management, or have had a phone call from the pharmacist and have interacted with the physician, so the results have come through. That’s about 7,000 total to date that have completed the full project. The results that we have seen come from a 23% enrollment. From that 23% enrollment, we’ve got about a 73% completion rate, and we’ve got about 81% of the medication therapy management reviews completed. 

Now the pharmacists are still working through some of the population that have not had the whole M.A.P. presented. 64% of the medication action plans resulted in a recommended change in some type of medication.

Gene-drug interactions: From report to physicians 

I’m going to give you some more statistics—these numbers are through May of 2019. When we look at the clinical side, we try to understand the implications of pharmacogenomic results on return on investment by analyzing medical claims and prescription drug information. We have the claim and pharmacy information through May of 2019. There were 5,313 patient medication therapy management reviews during that period and 3,401 of those required a medication change. For those with medication change, they may have been due to a lifestyle factor, or it may have been due to a drug-to-drug interaction. Critically, over 25%—1,463 of the 5,313 medication reviews—were specific to a pharmacogenomic impact where a drug needed to be changed because of a noted gene-to-drug interaction. 

That’s 27.5 percent of the total, which kind of rings true when you think about the overall percentage of numbers of medications and people that have that gene-to-drug interaction. It’s right about 30%, so it falls in line with the percentages that we know are out there.

With vs. Without PGx testing: Realizing the benefits of PGx information

Another interesting fact here is that when the pharmacist did call the physician and they recommended a change in a drug, 87% of the recommendations were accepted by the physicians. I think that’s a large number and it’s impactful. We know that the pharmacists had to put a lot of effort in educating the physicians. The fact that 87% of recommendations were accepted is significant.

The other interesting figures within the Teachers Retirement System came from looking at members that had taken the pharmacogenomic test and matching those against people with similar risk demographic profiles who did not take the test.

When we’re comparing those two groups, there was a 14% reduction in the cost to the plan spending of the group that took the test after 16 months. In addition there was a 3.2% increase of plan cost in the group that didn’t take the test which had a similar demographic and risk profile. Again, another relatively significant finding from the pharmacogenomic project that we’re doing.

PGx and Clopidogrel: A life-changing moment for the patients

Clopidogrel is one of those drugs that has a high incidence of gene-to-drug interaction. There were a couple of members that presented to the hospital with a heart attack. They went into the hospital, a stent was put in, and they were released from the hospital with a prescription for Clopidogrel. Both of these members, after leaving the hospital, had the foresight to say, “Hey, we just did this pharmacogenetic test with the Teachers’ Retirement System, let’s call KnowYourRX pharmacists and make sure that this prescription works for us.”

In both those cases, the prescription of Clopidogrel would not have worked; it would have been like taking M&M’s. Then, a call was made to the doctor, who made that change in medication. When we look at situations like that, that’s life changing.

I mean we could save a life in a scenario such as that, and those are real lives. What’s the cost of a life?  

The results are impressive! What are some barriers or challenges you’ve seen around the adoption of pharmacogenomics at the point of care?

The limitations of the program and the results come in with the dissemination of that information. As we all know, there are many electronic medical records that are floating around in different physician offices and hospitals.

Those electronic medical records typically don’t talk to one another. There has not been a great uptake by some of these larger electronic medical record companies to pull in the results of pharmacogenomic testing or the medication action plan that’s developed using other factors. 

It becomes an issue when a member goes to the hospital and that hospital doesn’t have the results built into the electronic medical record. How do they know what dose, what drug to prescribe if they don’t have this information available? They don’t have the full information about the patients, even though the information is out there somewhere. 

(Related Post: Interoperability in Healthcare: Is It Living Up to The Hype? [Podcast])

How long does it take for a pharmacist to do a medication action plan?

When we first started out the project, we didn’t know what that answer was. Some take a short amount of time. To give you some background information, there are now 15 pharmacists within KnowYourRX coalition and we have had as many as three dedicated to this project. 

On average, it takes at least one hour for each member on the phone with the physician and/or the member to create the plan. That one hour doesn’t include the time to load the information, but to create what they need for the medication action plan. It is time intensive. 

It’s interesting from the pharmacist’s point of view. This takes the pharmacist out of their normal role. The pharmacists that are working in this project absolutely love working with the members because they can see the results of what they’re doing; they have an impact on a member’s life and they find it extremely rewarding. 

PGx in PBMs: The way forward 

We are working with a couple of PBMs on what might end up being a novel approach: trying to integrate the results of the pharmacogenomic testing and the medication action plan to create an add-in, like a prior authorization, that a PBM might use with a pharmacist at a point of sale.

The idea being that if we could create a way to forward this information to the pharmacist at the point of sale, that pharmacist could then look at it as a member presents at a pharmacy. You could get around the issue with the electronic medical record and be able to possibly stop a gene-to-drug interaction at the point of sale, given that they already have information on drug-drug interactions.

Conclusion

What a fascinating discussion about the TRS Kentucky’s personalized medicine project with Curt. There are many factors that listeners should note and consider when setting up similar pharmacogenetic deployment programs.

Having the pharmacists at the core of PGx implementation is essential, as they are in a position where they can put PGx information to use. They are highly trusted and have frequent interactions with patients and the doctors, so they can respond to concerns or questions on both sides of the equation.

PGx implementations are motivated by the desire to improve the health of individuals, and can lead to deprescribing and other positive health outcomes. These can reduce costs, as fewer medications need to be purchased and improvements in wellness result in lower utilization of health services. 

We look forward to catching up with Curt again as we hear more about the project going forward. 

About Precision Insights podcast

The Precision Insights podcast is a podcast series consisting of inspiring conversations around precision medicine with industry thought leaders and innovators. Every two months (and sometimes more), we share the most cutting-edge technologies, processes, and initiatives in precision medicine. If you’re a patient, healthcare provider, employer, or someone simply interested in precision healthcare, you’re sure to find something useful in each episode. We hope that you’ll join our listeners and start taking control of your health, or implement precision health into your workplace/clinics a result!

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