​ interview

Optimizing medications for patients

Terry McInnis, MD, MPH

President and Co-Founder, GTMRx Institute

Please tell us about the mission of the Get the Medications Right (GTMRx) Institute.

Our vision and mission are very simple, but our mandate is profound. Our vision is to enhance life by ensuring appropriate and personalized use of medication and gene therapies. Our mission is to bring together critical stakeholders bound by the urgent need to optimize outcomes and reduce costs by “getting the medications right.” Our key initiatives involve active workgroups focused on practice transformation and care delivery, HIT/analytics and AI enablement, precision medicine and advanced diagnostics integration, and policy and payment alignment.

What are some perspectives on this mission from the organizations you worked with to found GTMRx?

Our founders include leaders, innovators, and stakeholders spanning the health care ecosystem, as well as payers and patient advocates. All of us believe passionately that we have the perfect storm to realize our mission as we move from fee-for-service to value-based care. One of our founders, Dr. Paul Grundy, may have summarized this perspective best when he said, “Effective use of medications is the issue of the decade.”

What can you tell us about the amount of money now spent on medications that are not “right” for patients?

In a study published in the Annals of Pharmacotherapy (https://tinyurl.com/mp-gtrmx), my colleagues and I found that illness and death resulting from untreated indications, drug interactions or adverse effects, subtherapeutic or toxic dosing, non-indicated therapy, and non-adherence—what we call “non-optimized medication therapy”—cost an estimated $528 billion in 2016, representing 16% of total U.S. health care expenditures. That figure includes only direct medical costs; it doesn’t include transportation, caregiving, lost productivity, or disability from non-optimized medication therapy. We also examined medical resources utilized when drug therapy isn’t optimized, such as additional medications and avoidable trips to an emergency department, hospitalization, and care in long-term facilities, all of which totaled $256.8 billion.

While many focus on non-adherence to prescribed medications, this is not the top drug therapy problem. Many patients need additional medications, differing doses, or—especially among the elderly—“deprescribing” or reducing dosages because of overuse. Until we make sure the medications are indicated, effective, and safe, non-adherence will only contribute to the problem.

​Effective use of medications is the issue of the decade.

How many patients suffer morbidity and mortality due to non-optimized medication therapy?

Our study revealed another tragic number: 275,689 avoidable deaths were tied to non-optimized medication use. Unfortunately, we believe this to be a conservative figure. Other statistics from the Lown Institute highlighted “medication overload,” which they defined as the “use of medications for which the harm to the patient outweighs the benefit,” in elderly patients. The institute reported that one in five older adults (10 million total) experienced an adverse drug event in 2018, resulting in 4.8 million outpatient visits, more than 660,000 ER visits, 280,000 hospitalizations, and 9,000 deaths. Many patients also experienced confusion, falls, nursing home stays, and poor quality of life. The Lown Institute report (https://tinyurl.com/mp-gtmrx2) also said that “Older adults are hospitalized for adverse drug events at a greater rate than the general population is hospitalized for opioids.”

Please describe comprehensive medication management (CMM).

Under CMM, physicians and pharmacists ensure that all medications are individually assessed to ensure that each one is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended. This boosts cost-effectiveness and ensures that all conditions are effectively managed, building the bridge from uncoordinated “trial-and-error,” population-based medication use to personalized, science-and-data-driven medication therapy.

It’s important to distinguish between CMM and other forms of medication therapy management (MTM). CMM is patient-centric, based on optimizing the clinical goals of therapy, reiterative (not “one and done”), and consistent with the definitions of the Patient-Centered Primary Care Collaborative. Our website lists 10 specific elements of CMM (https://tinyurl.com/mp-gtrmx3). Many organizations have taken to calling what they do “comprehensive medication management.” They may do two or three components, but no more.

How can physicians and pharmacists better coordinate medication-based care?

In advanced team-based care models, clinical pharmacists are part of the care team and work collaboratively with physicians, nurses, and other providers. Six of the 15 organizations we featured in our national “Get the Medications Right” snapshot of expert practices are in Minnesota: Goodrich Pharmacy, HealthPartners, North Memorial Health Care, Fairview Pharmacy Services, Hennepin Healthcare, and University of Minnesota Physicians. The University of Minnesota team at the Health-systems Alliance for Integrated Medication Management (HAIMM) has not only developed a way to successfully integrate the care team, they’ve also led the important work to measure patient satisfaction.

We also can learn a lot from the Department of Veterans Affairs (VA)’s work to systematically integrate clinical pharmacy specialists (CPS) into the care team to accomplish CMM within both the primary care and specialty teams. More than 4,350 of their CPS (all in non-dispensing roles) provide CMM services, accounting for almost 6 million patient encounters yearly.

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How can in-house pharmacies inform physicians about new medications?

In-house pharmacists can not only help physicians keep pace with the continuous stream of new medicines entering the market, they can help put those new therapies in context of what other medications their patients are taking. The dispensing pharmacists can also ensure that the clinical pharmacists in collaborative practice settings are advised when adherence issues or formulary changes arise. When the physician and pharmacist are working under the same roof, interacting with the same patients, and accessing the same platform, coordination is much greater.

In your first year, you have been developing a “Blueprint for Change.” Please describe this.

Created by our membership, the Blueprint for Change—to be released in early 2020—will guide our work by laying out specific actions we can take to be a catalyst for change. We’ve established four workgroups focused on practice transformation and care delivery to support CMM implementation, policy and payment changes necessary to support the practice, and steps to ensure that precision medicine and advances in diagnostics are realized at the point of care, with the health information technology and AI necessary for clinical decision-making and workflow practice support. Members and nonmembers can learn more at https://gtmr.org.

What other core message would you like to share with physicians?

Physicians know that 80–85% percent of the way they treat and prevent disease is through medications. Physicians are very good at prescribing drugs for individual patients, but when you factor in all of the drugs prescribed by various specialists and primary care providers, it can lead to the current drug therapy problems.

Also, we are at a key inflection point as we move from population health/clinical guideline-based care to precision/personalized medicine influenced by advances in genomics, tumor genetics, the microbiome, and more. The fact that over 70% of the medications in the pipeline have complementary or companion diagnostics means that we have to not only implement CMM into practice, but make sure we have the HIT/analytics and evolving AI to inform decision-making for medications and diagnosis at the point of care.

Physicians must lead this transition so our patients are confident they have the most effective, appropriate medications and evolving gene therapies as we optimize health. Join us!

Terry McInnis, MD, MPH, is President and Co-founder of the GTMRx Institute and President of Blue Thorn Inc. She is board-certified in preventive and occupational medicine and is a Fellow of the American College of Occupational and Environmental Medicine.