The Road to Value-Based Care: The Polypharmacy Crisis
As healthcare providers continue the move toward value-based care, the focus shifts from treating episodes of sickness to wellness and measuring effectiveness of treatment. Greater percentages of revenue are tied directly to the new performance indicators and managing risk and associated cost are at the forefront of value-based success. A previously unrecognized obstacle to managing these patients is now becoming clear. Polypharmacy, often defined as the use of 5 or more prescription medications, has become an significant problem in the United States. Polypharmacy is present in nearly 20% of the U.S. population and 40% of the population over 65 years or age. The estimated cost from the related complications exceeds $177 billion a year. The impact is significant and includes escalating drug costs, impaired patient functional and cognitive status, unnecessary physician visits, ED encounters, hospitalizations and other costly consequences. Rising prescription drug costs account for more than 23% of every insurance premium dollar – outpacing physician, inpatient and outpatient hospital services.
As noted, this complex issue primarily impacts the elderly who are at even greater risk for adverse effects:
40% of Americans 65 and over are taking 5 or more prescription medications with 30% taking 8 or more
For Americans over 65, 34.5% of all ED visits are from Drug Related Problems (DRPs) and 43.6% of those visits resulted in an admission with nearly double the average length of stay (ALOS) at 7.69 versus 4.46 days without a DRP
Increased frequency of prescribing cascades where the side effects of medications are misdiagnosed as symptoms of other problems resulting in further prescriptions, further side effects and unanticipated drug interactions.
Addressing the Polypharmacy Problem
Polypharmacy is most often present where a patient with multiple chronic diseases is under the care of multiple physicians (including a PCP and specialists), often on separate electronic health records (EHRs) and unaware of the other’s treatment plans and medication therapies. In addition, rising drug costs and increased out of pocket expense has driven patients to pharmacy shop to find the lowest cost option. This has further fragmented the patients clinical record and creates a barrier to a pharmacists’ medication management oversight. Solving the challenges of polypharmacy demands more than traditional medication management. A patient centric approach to assessing each medication and their benefits vs. risks is required to achieve lasting results. The patient’s conditions, medications (Rx, OTC, nutraceuticals), pharmacogenomic profile and patient specific information must be taken into consideration. This complex engagement of the patient, family and multiple caregivers most often falls outside the individual physician and onto the Care Management team. The Care Manager coordinates care delivery and engages the providers and patient in ways to drive improved outcomes and reduce unnecessary utilization including ED visits and hospitalizations.
The Solution
An effective approach to solving the polypharmacy issue combines evidence-based clinical and medication related knowledge, state-of- the-art pharmacogenomics (PGx), and a patient’s personal information to go beyond traditional drug interaction checking. This approach uses information on each patient’s genetic variation to determine the full impact of a medication on the individual. Without PGx it can be difficult or impossible to predict:
Will the patient receive the expected level of benefit from a medication?
Will they receive any benefit from this medication?
Will they experience an adverse response to this medication?
Pharmacogenomics is a highly cost-effective solution to assist providers in developing safer, more cost-effective, therapeutic treatment regimens tailored to a person’s unique genetic makeup.
According to the FDA, pharmacogenomics (PGx) can play an important role in identifying responders and non-responders to medications, avoiding adverse events, and optimizing drug dose. Combining pharmacogenomics, clinical analytics, patient supplied data with advanced drug-drug and drug-gene interaction checking allows this approach to analyze and report on a patient’s unique medications, allergies, diagnoses, and chief complaints to discover existing and potential future complications. This approach completes individual checks to assess clinical and genetic conflicts including previously unseen drug interactions, prescribing cascades, medication burdens and drug-gene interactions. The result would be actionable dashboard outlining a summary of patient medications, clinical findings, genetic abnormalities identified, potential risks and considerations for improved medication therapy that deliver a quantifiable return-on-investment. Care Managers are then enabled with the data necessary to engage the right physicians and recommend effective cost and clinically effective adjustments to medication therapy.
Benefit models estimate a significant financial impact:
Cost Reduction – reducing the overall number and cost of prescription drugs
Cost Avoidance – reducing drug related problem (DRP) physician visits, ED encounters and hospitalizations. Studies show avoidable annual DRP costs for individuals 65+ are in excess of $8,000,000 per 10,000 for physician office visits, ED encounters and hospitalizations alone
Revenue – the CMS Medication Therapy Management Program allows for an annual billing of $120-150 per member to review and assess effectiveness and compliance of prescribed medications
The World Health Organization estimates that over 180,000 Americans die annually from adverse drug reactions, and over one million will be injured, making it the 4th leading cause of death. This approach delivers actionable data and measurable results addressing one of today’s most expensive and complex clinical problems.
*Data references available upon request
