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Pharmaceutical advancements have played a major role in improving the United States’ health and life expectancy. But for many, non-optimized medications have resulted in serious side effects, hospitalizations, or even worse health outcomes. In fact, 750 adults age 65 and older are hospitalized each day because of adverse drug events. In a recent Arine webinar, Dr. Terry McInnis, MD, MPh, CPE, Advisor and Chief Medical Officer at Arine, uncovered the true cost and how to optimize medication to improve health equity and patient outcomes.

In the webinar, Dr. McInnis discussed the following topics:

  • The financial and economic toll non-optimized medication therapy takes on patients, providers, and plans
  • The difference between medication therapy management and comprehensive medication management (CMM)
  • Actionable strategies to implement CMM and improve health equity and cost outcomes

You can watch the full webinar here or keep reading for a summary of how to leverage AI-driven comprehensive medication management to optimize medication.

Why Non-Optimized Medications Cost Us Billions

Improper drug utilization has a huge impact on the economy. In 2016, non-optimized medications cost $528 billion, or 16% of annual healthcare costs.

That $528 billion went toward preventable interventions such as:

  • Almost $272 billion in long-term care admissions
  • $174 billion in hospitalization costs
  • Almost $38 billion in additional provider visits
  • $37 billion in emergency department visits
  • Almost $8 billion in additional prescriptions

And the cost of non-optimized medications is still rising. Based on Dr. McInnis’s projections, in 2020 numbers, non-optimized medications likely cost an estimated $659 billion in preventable healthcare spending and hundreds of thousands of lives lost.

What if We Could Save $659 Billion Each Year Instead?

According to the 2021 National Trends in Drug Expenditures study, pharmaceutical spending in the U.S. totaled $535 billion.

Considering the economic impact of drug expenditures, it’s easy to see why payers examine the cost of medications in terms of product and formulary structures. But maybe we need to think about it differently. Instead of having such a narrow focus on pharmaceutical spend, what if we also turned our attention to clinical outcomes? Do we have the right drug, for the right patient, at the right dose, used the right way?

If we saved $659 billion by starting to optimize medication, we could cover the cost of all drug expenditures with $100 billion of cost reduction remaining. Fortunately, we can now integrate the data and deploy analytic and clinical solutions that can address this problem.

The Human Cost of Non-Optimized Medications

Beyond the financial cost, the human toll of non-optimized medications is 276,000 lives lost per year, or just over 750 people per day. With such a high cost to human life, organizations must implement strategies to improve drug utilization if we are serious about health equity and financial stability in healthcare.

Medication adherence is often considered the top contributing factor to optimizing medication use. Even federal agencies like the Center for Medicare and Medicaid Services (CMS) assign almost one-third of a health plan’s quality score towards adherence. These scores determine payer reimbursement, making adherence initiatives a top priority for health plans. However, if the medications are not indicated, effective, or safe for a patient, asking them to be adherent to a medication can be dangerous—or even deadly. So yes, adherence is an issue, but it’s not the only concern. It’s not even the top medication-related problem.

According to a study published in the Annals of Pharmacotherapy, developed by Hepler and Strand, there are eight categories of drug-related challenges:

  • Untreated indication
  • Improper drug selection
  • Subtherapeutic dosage
  • Failure to receive drugs
  • Overdosage
  • Adverse drug reactions
  • Drug interactions
  • Drug use without indication

To illustrate just one drug-related problem, untreated indication, consider hypertension. Research from the World Health Organization estimates that 700 million people are living with untreated hypertension. This chronic condition leads to cardiovascular issues which account for the highest morbidity and mortality rates in the world. In the US alone, more than one-third of all deaths are attributed to heart disease or stroke. Untreated indications also place a burden on the economy, costing the healthcare system $216 billion per year. Although cardiovascular disease is a huge health and economic problem, antihypertensive medications can easily manage cardiovascular conditions at a low cost.

Care organizations must look at more than just adherence to optimize medications. All categories of drug-related problems should be addressed when reviewing a patient’s medications, as any of the eight above-mentioned challenges can cause poor health outcomes.

Patients should not only have access to treatment, but they should also receive the correct dosing to maximize the drug’s effectiveness. Both underdosing (dosages too low) and overdosing (drug toxicity) can cause severe morbidity or even death.

A Medication Challenge Often Overlooked

According to the Lown Institute, medication overload is defined as the “use of medications for which the harm to the patient outweighs the benefit” and is “America’s other drug problem.” Elderly patients in particular have a higher incidence of medication overload.

The Lown Institute estimates adverse drug events have more than doubled since 2008.

  • Ten million instances of adverse drug events
  • Almost five million outpatient visits
  • More than 660,000 ER visits
  • 280,000 hospitalizations
  • 9,000 deaths

Research also shows older adults are hospitalized for adverse drug events at a greater rate than the general population is hospitalized for opioids.

To understand why the costs of non-optimized medications are so high and the health outcomes so poor, we need to look at why medication therapy management isn’t working.

Why Traditional Medication Therapy Management Doesn’t Scale

Traditional MTM may allow payers to discover less expensive or reduce duplicative therapies or drug-drug interactions for its members within only the context of currently prescribed medications (the drug silo), but it doesn’t provide a scalable solution that can address the clinical goals of therapy and the all of the drug therapy problems such as indication and effectiveness within the clinical context. Here are a few reasons why:

  • Reactive approach to medication problems. Health plans have a limited ability to catch medication-related problems before they arise.
  • Lack of coordination between prescribers. Patients may see multiple physicians/clinicians for multiple conditions, who may be excellent at the medications they prescribe, but not understand the implications of the medications prescribed by colleagues in other specialties. Patients often end up with combinations of medications that are suboptimal, or dangerous.
  • Underutilization of clinical pharmacists. Pharmacists are not included on healthcare teams like other providers, leading to missed opportunities for multi-disciplinary collaboration and patient care.
  • Narrow focus on quality metrics. Traditional Quality Metrics (ie STARS/HEDIS measures) are mostly adherence-focused versus clinical outcomes-focused. Outcomes-focused metrics result in greater cost and outcomes improvement.
  • Lack of actionable insights from the data. Legacy systems and disaggregated claims and clinical data as well as difficulty synthesizing available data make optimization of medications impossible.

The Expansion of Comprehensive Medication Management

Health plans that implement comprehensive medication management programs see reduced cost of care while improving patient outcomes. It’s a scalable strategy that provides an opportunity for collaborative practice between pharmacists, physicians, and other providers.

Physicians could also benefit from this multi-disciplinary team-based approach as well. The U.S. physician shortage is predicted to climb to 122,000 by 2032. Furthermore, within an average office visit time of 15 minutes, physicians spend an average of 26 seconds on guideline-recommended education, and 23 seconds on all other aspects of a new prescription.

Pharmacists must be integrated into team-based care to allow for proactive drug interventions that address gaps in care. Many studies show the positive impact of pharmacist-led interventions on clinical outcomes. For instance, when pharmacists are integrated into payer medication management programs, patients see:

  • Improved clinical outcomes
  • Increased cost savings
  • Higher patient satisfaction

A Tech-Enabled Learning Approach that Turns Data Insight into Action is Revolutionary in Enabling Medication Optimization

Technology plays an important part in the advancement of comprehensive medication management. Health plans can use advanced AI-enabled CMM programs to provide patients with the most cost-effective therapy while maximizing clinical outcomes. How? By finally aggregating the clinical, claims, and real-time patient data to understand and solve the drug therapy problems in a patient-centric fashion. When social determinants of health (SDOH) and equity/cultural issues are addressed directly with patients, you can optimize medications to reach the clinical goals of therapy i.e., control hypertension, diabetes, or schizophrenia episodes.

Data insights provided by AI-powered platforms allow health plans and provider groups to address gaps in medication management by proactively:

  • Identifying the most effective medications and dosages
  • Identifying the safest medications and dosages
  • Improving access to care through appropriate referrals
  • Providing tools to enhance health literacy among patients
  • Addressing equity by matching patients with linguistically and culturally relevant providers and needed services/benefits of the plan/community
  • Equipping providers with evidence-based medication recommendations

Medication-related clinical and claims data collected through artificial intelligence helps put together the full medical picture of a patient. This ultimately leads to optimal interventions and reduces the total cost of care.

Key Takeaways

If your medication management program operates within the traditional MTM model, your organization could be missing tools and data that optimize costs as well as clinical outcomes.

So where do you go from here?

Dr. McInnis shares four actionable strategies, all enabled by intelligent analytics, for health plans and providers looking to enhance their medication management programs:

  • Un-silo medication management. The impact of medication management should be measured by optimized clinical outcomes and reductions in the cost of medication care – not just through filling prescriptions.
  • Empower clinical pharmacists with the tools and data that help them intervene collaboratively and proactively to improve access to care for their patients.
  • View medication management as a medication optimization opportunity, not just an adherence problem.
  • Include CMM services as an essential offering in value-based care. Change benefit plan design and value-based contracts to include CMM services for patients.

Arine provides healthcare organizations with innovative, AI-enabled solutions for medication management. To learn more about how AI-enabled comprehensive medication optimization delivers outcomes for patients, providers, and plans, download our white paper.

Blog Posts
Post by Tenicia Talley, PharmD, MSCR
September 14, 2022
Tenicia Talley, PharmD, MSCR, is a managed care pharmacist. She writes about medication management, medication intelligence, and health equity.