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528.4 Billion Reasons Medication Optimization Matters

by Hope Chang, PharmD, AAHIVP

When you’re a friendly neighborhood pharmacist you get all sorts of questions regarding medications. “Can you get me X, Y, or Z medication? Do I need a prescription? Does my doctor really want me to take these medications every day? What happens if I just stop?” Now, a question patients don’t typically ask, but their providers do is: “How do we optimize my patient’s medication regimen?”

For those unfamiliar with the term, medication optimization refers to a process where a patient and their care team evaluate the patient’s medications and optimize the regimen for that particular patient. In other words, medication optimization ensures that the right patient gets the right medication at the right time. While many patients would benefit from medication optimization, it’s not always feasible given finite resources and silos with healthcare. If built correctly, virtual care can bridge the gaps and expand the reach of medication optimization services. Before we dive into that, let’s touch on the importance of medication optimization, including its impact on costs.

Why is medication optimization important?

An optimized medication regimen can improve health outcomes, enhance the patient experience, reduce costs, and improve work life for other clinicians. Oftentimes, these improvements have a domino effect.

For example, when you cater a patient’s medication regimen to align with their lifestyle—e.g. removing medications that need to be taken with food for people who report an irregular eating pattern—or budget, they’re likely to improve their medication adherence and compliance.

The downstream effect of better medication adherence is improved clinical outcomes.

Medication optimization services can also help overcome clinical inertia—the provider’s failure to initiate or intensify therapy according to guidelines.  Clinical inertia is a common challenge in managing chronic conditions, with rates exceeding 50% for patients with type 2 diabetes. This phenomenon is a major concern, as prolonged hyperglycemia leads to diabetes-related complications such as kidney disease and blindness.

The cost of poor medication optimization

Many times when people hear cost savings and medications, they automatically think medication deprescribing—getting off medications. While this is one way medications can be optimized, it’s not the only way.

One analysis estimated the annual cost of non-optimized medication therapy in the U.S. to be $528.4 billion.

M Health Fairview, an integrated health system, looked at the impact of having a pharmacist onboard to provide comprehensive medication management (CMM)—a process pharmacists use to optimize medications. They found that after one year, patients who had received CMM services had an average cost of $8,197, and those who didn’t had an average of $11,965. That’s more than a 30% reduction, which led to a 12:1 ROI.

Having a medication management specialist on board can also improve work life and job satisfaction for other members of the care team. For providers specifically, having a pharmacist—whose primary role is managing medications—on the team allows them to focus on diagnosing and treating their patients. When surveyed, a large majority of physicians, nurse practitioners, and registered nurses responded that having CMM services improved their job satisfaction.

What does medication optimization look like in traditional practice?

I remember a specific example from my days in clinic when the pharmacy notified me that one of our patients refused their insulin. When I called the patient to confirm, he said he wasn’t taking insulin anymore, because he was gaining too much weight—a common side effect of insulin.

In fact he had stopped using it months prior, but was afraid to tell anyone so he kept letting the pharmacy fill it. I met with his provider and suggested trying a GLP-1 medication, as GLP-1s reduce A1c and can cause weight loss. However, the provider was concerned about insurance coverage and whether the patient would be willing to try a new medication—as this was in 2019, before GLP-1s became a household name.

It took a little elbow grease, but within a week the patient was picking up Trulicity (dulaglutide) from the pharmacy and then meeting with me to learn how to inject the medication. At his next follow up appointment, I popped into the room to see how he was doing. At first, I thought I had gotten the rooms wrong, because the patient in front of me was in high spirits. His new medication was easy to use, only injected once a week, and he reported walking more, losing weight, and taking less pain medication! Moreover, he’s thankful to his care team for listening and finding a different solution for him.

Later, a different provider in the same clinic came to me with a similar patient scenario, and wanted to start his patient on the same medication. However, after talking to the patient, we learned they had extreme needle phobia and didn’t want to inject themselves. In this case we told the patient there was one oral option, Rybelsus (semaglutide), but it was a daily medication rather than weekly, and they might have more stomach pain or other GI-related side effects. They were comfortable with that risk.

These examples demonstrate that medication optimization requires shared decision-making between care teams and patients, as well as time, expertise, and attention to detail.

Are there examples of success in the virtual health space?

While measuring medication optimization can be challenging, there are examples in the literature that we can look to. Coming back to the phenomenon of clinical inertia in diabetes care, we know insulin is a very effective medication for lowering blood sugar. However, it’s an injection, which can be a nonstarter for some patients. The medication also has a high risk of hypoglycemia, so patients are often asked to monitor their blood sugar more often, to make sure they don’t have dangerous lows, and if they do go low, how to manage their hypoglycemia with the 15-15 rule. All of this can make providers wary if they aren’t sure if the patient is ready to self-manage. What tools could providers and patients use to ease overwhelming situations like insulin initiation?

Enter programs like Omada Health, which provides between-visit care and bridges the gap between patients and providers to fill the space between doctor’s visits. Omada’s program connects members with a dedicated care team, which for the diabetes program, includes a Health Coach and a Certified Diabetes Care & Education Specialist. Armed with data from connected devices such as BGMs and CGMs, Omada’s care teams work with members to help them manage their condition safely and effectively.

When researchers looked at different digital tools being evaluated for diabetes management, the key outcomes varied from study to study, but most interventions saw a reduction in A1c. Study participants also reported better treatment satisfaction and diabetes condition knowledge from the interventions.

Onduo—a virtual diabetes care program—did a unique analysis, evaluating medication optimization, management and clinical inertia during a four month prospective study. While the study had its limitations, researchers felt that the program and its features were able to help overcome clinical inertia, as participants were able to seamlessly have their medications adjusted.

The path forward for medication optimization in virtual care

So how should we tackle medication optimization in the virtual health sphere? I’m not exactly sure. In fact, I don’t think there’s one way, but what I do know is that for our patients’ sake we shouldn’t replicate traditional healthcare and operate in silos.

In the traditional practice example above, the scenarios were seamless for the patient, because my office was five steps away from the pharmacy and 10 steps away from the provider. I also had access to both the clinic electronic health record (EHR) and pharmacy processing system (typically two separate platforms even in integrated health systems), which allowed me to be a manual link between the clinic and the pharmacy.

Too often, CMM and Medication Therapy Management (MTM) services conducted at a pharmacy or a health plan fall short due to lack of visibility of the patient’s health record and fragmented communication with the patient’s broader healthcare team. I see the same potential issues happening with medication optimization-focused point solutions, if they don’t invest in interoperability and integration into other areas of the patient’s healthcare system, and even that has challenges for a modern digital health company.

Medication optimization is a critical component of improving patient outcomes as well as their experience in the healthcare system. Digital health tools that connect patients to care teams and work with them in the space between visits are well positioned to provide these services for members.


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This Proof Points edition was originally published on LinkedIn on 10/30/23.