How managing medications based on genetics can enhance quality-based payments

An individual's genome dictates how he or she responds to prescription drug treatments. Genetic variability can render a medication or dosage ineffective and even harmful, leading to drug-related complications that could land a patient back in the hospital — at a cost to both the patient and provider.

Readmissions related to adverse drug reactions can negatively affect the quality metrics government and commercial payers use to calculate value-based reimbursements. This can put financial strain on hospital systems of all sizes. Analyzing which medications work best for individuals based on their genome, known as pharmacogenetics, and involving pharmacists in medication management offers several benefits, including a reduction in avoidable post-treatment hospital visits.

Tailored prescription drug selection to help reduce hospital readmissions

Pharmacogenetic practices have lowered drug-related complications and spared added costs for providers, according to a genetic testing initiative for patients taking blood-thinning drugs at Chicago-based University of Illinois Hospital & Health Sciences System.

UI Health's study included 800 patients who were genotyped for blood thinners warfarin and clopidogrel in the first phase of the testing. As a result, drug-related complications leading to hospital readmissions decreased by 68 percent within 90 days of discharge. Since 2012, UI Health saved an estimated $2,043 per patient and nearly $600,000 annually.

UI Health's pharmacogenetic pilot holds promise for improving patient care, Matthew Rutledge, co-creator and president of pharmacogenetic testing company MD Labs in Reno, Nev., said in an interview with Becker's Hospital Review. By optimizing genetic information, he says hospitals may reduce instances of readmissions related to adverse drug reactions during the first phases of treatment for a range of conditions, including heart disease.

Enhanced reimbursement for heart disease patients under bundled payment model

In December 2016, CMS finalized a mandatory bundled payment program for heart attacks and bypass surgeries, expanding the existing Comprehensive Care for Joint Replacement model. Beginning July 1, 2017, government payers will hold acute care hospitals in over 1,000 markets accountable for the cost and quality of treatment provided to heart attack and coronary bypass patients beginning with hospitalization and extending 90 days post-discharge.

Under the bundled payment model, if spending for an episode of care for heart attacks or bypass surgeries exceeds CMS' target price, hospitals are financially responsible for the difference to Medicare up to a specified limit. Drug-related complications can extend the episode of care beyond CMS' 90 day threshold, leaving hospitals incurring higher costs than the bundled payment allotted for and absorbing the expenses.

"Even before the CMS cardiac bundle became finalized, we have been thinking of the importance of pharmacogenetics," said Devang Desai, MD, director of interventional cardiology at Saint Mary's Regional Medical Center in Reno. "Incorporating pharmacogenetics will become more important going forward for high-risk cardiac and acute coronary syndrome patients when trying to obtain desired responses to critical medications."

In addition to the power pharmacogenetics yields over treatment effectiveness, pharmacist involvement in patient care planning is also critical, say Mr. Rutledge and Dr. Desai.

Improved outcomes, reduced healthcare costs when pharmacists are involved

Including pharmacists in determining which medications correspond best with each patient can reduce hospital readmission rates by up to 50 percent for heart disease patients, according to a report published in the American Journal of Health-System Pharmacy.

"We fundamentally believe the pharmacist can play an important role in pharmacogenetics," said Chuck Dushman, vice president of marketing and business development of Rxight, a pharmacogenetic program developed by MD Labs. "Pharmacists have insight into all of a patient's medications and medication history and are positioned to communicate with each provider, not just one specialist."

Mr. Dushman said this does not mean bypassing the provider, who still controls what is prescribed to a patient and is more informed about a patient's medical history. However, pharmacists can serve as an expert resource to determine correct drug-gene interactions. Over time, this precision can help curb unnecessary readmissions that lower quality-based payments.   

"Research continues to uncover more connections between patient genetics and medication response," Mr. Rutledge said. "One day, we will know the perfect candidate for the medication and we will look at [this] as if it was the Dark Ages. The use of pharmacogenetics will be just something we do."  

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