The United States spends more on health care than any other country, estimates are approaching 18% of GDP. Those studies suggest up to 30% of that spending may be considered waste. This waste can come in many forms, from over insurance, to overpayment, misdiagnosis, misaligned incentives, and outright fraud, among others.
I have spent the last 10+ years in the employer benefit space focused on solutions that will create better distribution of health insurance to minimize the inefficiencies that exist. The intention has been to maximize the employer’s investment in employee’s health and outcomes.
Over the past 3 years I have seen the pharmacy benefit of those plans explode in terms of cost. There are several factors driving this, from the vertical integration of PBMs and consolidation to misaligned incentives that lead to over prescribing. Everyday, new business models are being created to unwind the oligopoly that has been created.
Today I want to focus on Pharmacogenomics (PGx) as an additional solution that is available to payers.
Pharmacogenomics is the study of the role of the genome in drug response. Its name (pharmaco- + genomics) reflects its combining of pharmacology and genomics. Pharmacogenomics analyzes how the genetic makeup of an individual affects their response to drugs. This is not new science; it has been studied extensively, beginning in the 1950’s. The term became popular in the 1990’s and the first approved FDA PGx test was in 2005. In its simplest form it will tell a patient and prescriber based on there DNA make up if a drug will work or not.
When you think of high utilizers, 5 or more therapeutics at the same time, the question becomes, how are they mixing and working together based on your specific DNA?
I recently became aware of the term ADI (Adverse Drug Interactions). Each year 4.5 million hospital visits are attributed to ADIs, accounting for up to 10% of direct health care cost. PGx test could eliminate 50% of ADI’s. A massive improvement in efficiency but way more importantly ADI’s are considered the 4th leading cause of death in the United States. Getting the drug mix and appropriate therapy right based on DNA is critical for the health and safety of employees.
Progress is being made. Many challenges exist in the infrastructure of the healthcare system to ensure prescribers have the appropriate information to ensure the best therapy will be prescribed. These pipelines are being built to make the information easily accessible at the point of care. Health plans are also starting to see the logic and efficiencies of covering the cost of a PGx test. UHC announced last year they will begin to cover this test specifically around the diagnosis of depression. It often takes 9 weeks to determine if an anti-depression medicine is effective, if not the cycle needs to start again with a new therapy. PGx test will eliminate that time and waste. This is just a small example but a green shoot for sure in the early adoption and coverage by health plans.
PBGH is here as a resource an advocate. We may have examples where we took an issue to a Health plan or PBM to make the logical case why a procedure or a therapy.
Kevin Holler is a Pharmacy Benefits National Sales Consultant for PBGH’s Group Purchasing Solutions
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