Episode 39 – What Should Employers Know About Pharmacogenomics?

Mike Stull (0:09) 

Hello, everyone, and welcome. Thanks for joining us on HR Benecast, your source for expert commentary and insights on current health benefits-related news and strategies. This is your host, Mike Stull. 

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All right, let’s get started. So, joining us today is Travis Baughn, Vice President of Clinical Solutions at OptumRx. Travis is a pharmacist who leads clinical product development initiatives at OptumRx, and he joins us today to share the latest in pharmacogenomics, the pros and cons, and what’s coming in the world of pharmacogenetics. I hope you enjoy the conversation.  

All right, thanks for joining us, Travis. To get started, tell the audience a little bit about your self. 

Travis Baughn (3:13) 

Hey, Mike, thanks for inviting me today. My name is Travis Baughn. I am a pharmacist by background. 

I have worked in the healthcare space for the last 10-15 years or so, primarily in clinical development roles for various PBMs and health plan organizations. Got a pretty big passion for clinical analytics, clinical engagement types of products, and currently work at OptumRx, leading clinical product innovation for the organization.  

Mike Stull (3:46) 

Excellent. 

So, we wanted to provide information for employers today about the topic of pharmacogenomics. Maybe we start off with some simple questions, like what is it?, and why is it important? 

Travis Baughn (4:00) 

Yeah, good question to start with. Pharmacogenomics is a long word, first and foremost, and often mispronounced, sometimes, of course, shortened to PGX, sometimes interchangeably used the term pharmacogenetics as well. 

So pharmacogenomics, you know, as a discipline in the healthcare system is, in essence, a study of how the body responds to certain medications, and more specifically, how the genetic makeup of a body is likely to impact the metabolizing of a medication, which downstream, I’ll get into this a little bit later, but downstream, how it could potentially work within the human body. So pharmacogenomics is the study of everything from A to Z in that space, basically your genes, how they encode proteins, and how those downstream proteins have alleles that impact your ability to metabolize medications.  

Mike Stull (5:05) 

For the non-clinician listening to the podcast, so saying that it allows your body to metabolize the medication is basically a clinical way of saying your body’s able to take it in and use it. 

Travis Baughn (5:22) 

Yeah, exactly. It’s very simply put, different people respond to medications differently, right? I think we recognize this. I think we’ve all been in scenarios where we’re chatting with family members or friends, and we all recognize that the likelihood of us to get the clinical benefit from a medication varies person by person. 

You might have some people who simply do not respond to a medication, doesn’t work. You might have some individuals that have drug reactions, right? They’re more sleepy perhaps, or have some sort of drug reaction that somebody else doesn’t. And the reality is there’s a lot of reasons that could occur. 

May or may not be genetics, but for a certain group of medications that are highly likely to be impacted by certain differences in metabolic pathways that your genetics may have, the reality is it could be being caused by variations in genetics. So yeah, it basically impacts you know individuals’ variations on their ability to process medications.  

Mike Stull (6:34) 

And I think that leads us down the path of answering the “why is it important?” question in terms of we want to make sure that medications work for people, but why else is it important, particularly for employers?  

Travis Baughn (6:51) 

Yeah, I think first, Mike, in the space of potential waste, and perhaps what I like to refer to as long and complex medication journeys that some patients have to go through. 

I’ll kind of touch on both of those. So first, from a waste perspective, there’s a lot of medications that, you know, if we had the ability to understand whether the body has a high likelihood of not responding to a medication, and that was available to prescribers when they were choosing the appropriate medication for a patient, I think we all could predict that a lot of prescribers would just not prescribe that medication, right? If you know it’s not gonna work, why prescribe it? What’s happening in today’s world, the vast majority of individuals have never completed a pharmacogenomics test, and thus they don’t have that information available to them. So the medications that get prescribed have a likelihood of not responding, and certainly if a patient is not responding to a medication because of their genetics, I think there’s a pretty compelling argument to make that that is a wasteful, you know, experience from a financial perspective, and I mean, honestly, maybe potentially wasteful for the prescriber’s time and the patient’s time as well. 

And that leads to the second point I made, which is long medication journeys. This is probably most prevalent in the psychiatric and behavioral health space. There’s a lot of medications that are impacted by pharmacogenomics that are behavioral health medications that treat conditions such as depression or schizophrenia, and often these patients really struggle to find the right medication that works for them, and it’s not uncommon for these patients to be on, you know, two, three, four, five medications at varying dosages before they find something that works. 

So the idea behind pharmacogenomics could really impact both of those, the waste side and I think the medication journey side as well.  

Mike Stull (9:02) 

Yeah, absolutely. I think an important thing for employers to know is, you know, especially with some of these depression medications, a lot of them have gone generic, they’re pretty cheap. So when you try to quantify the waste, it can be low in terms of dollar amounts, but you have to take into account all of the lost productivity, absenteeism, and just the general patient experience, what these folks are dealing with from a mental health perspective. And, you know, the sooner you can get them on a medication that’s going to have positive benefits for them, you know, the better quality of life they’ll have, and hopefully the better quality of work that they can contribute to the organization or the team.  

Travis Baughn (9:54) 

Yeah, I totally agree with you. And you brought up a key point, which is, you know, understanding the value that pharmacogenomics is bringing to the healthcare ecosystem is, of course, largely contingent upon quantifying, you know, that waste component that I mentioned, and also that, you know, impact to that long medication journey perspective as well. And I think, given that a lot of these medications are low in cost, it does, you know, put us in a position of really needing to understand how those elements that you just suggested translate to benefits to plans.  

And it’s difficult for sure. But what we found is, you know, within a population, it’s all about finding who’s the most likely to benefit, stratifying that population in a way that ensures that who you’re connecting to pharmacogenomics testing is not producing unintended waste of paying for pharmacogenomics tests as well, right? Many of us have completely normal genetics and are most likely not on medications that would even be impacted by pharmacogenomics types of genetic associations. And so why test those populations, it’s really about identifying the populations that are most likely to benefit. So in the behavioral health space, it’s the individuals who have tried and failed at least one therapy. 

In the chronic disease space, it’s patients who have polypharmacy issues, it’s patients who are on certain medications that have the most kind of compelling argument around the role that pharmacogenomics plays and the clinical benefit that the medication is seeking to achieve. So all of those, you know, tie together into an interesting, I think, value perspective to payers, but one that we certainly still have some work to do on within the healthcare world to evolve.  

Mike Stull (11:55) 

So you talked about which patients need testing, could you tell us a little bit about how the process works and how patients actually get tested for pharmacogenomic programs?   

Travis Baughn (12:11) 

Sure. So the test itself, Mike, is relatively very simple to complete. It’s in essence, a cheek swab sent to a lab that then results in the lab processing the sample that’s sent in and producing a lab report that outlines all of the pharmacogenomics findings from that test.  

The process of the patient connecting to pharmacogenomics, though, is much more complicated. And I think that’s probably the context of your question, which is really what initiates pharmacogenomics testing within the healthcare space. And the reality is, it can be initiated a lot of different ways. I would like to be, you know, say, I would like to say that prescribers are the ones that are kind of embracing pharmacogenomics and understanding the value that it can deliver at the point of prescribing.  

But the reality is, today, prescribers, I think, have some healthy skepticism around pharmacogenomics that has been caused, most likely by some chaotic, you know, pharmacogenomic lab practices in the industry that have resulted in, you know, a lot of PGX labs across the country, producing labs that aren’t incredibly consistent in their findings, and also going directly to patients and kind of overpromising the actual effect that pharmacogenomics testing can have on a patient population. So as far as patients receiving pharmacogenomics testing, there’s companies that patients can go to directly for certain medications and certain prescribers. Prescribers certainly can connect patients to pharmacogenomics testing. 

Or also on the payer side, health plans, PBMs also have pharmacogenomics testing products that they also offer patients as well. So there’s a lot of different avenues by which patients can get connected to pharmacogenomics testing. And honestly, it’ll vary kind of patient by patient on how they get connected, but it’s most likely going to be driven by a medication that they’re on having a high likelihood of benefiting from a pharmacogenomics test. 

Mike Stull (14:43) 

And do pharmacogenomics tests, do they test for a specific medication? Are they looking for a specific marker for a particular medication? Or are they more like the 23andMe where they look at everything and give you kind of a whole profile of an individual?  

Travis Baughn (15:05) 

It varies. You certainly can’t, some labs have very specific panels that target one, you know, one specific genotype and allele that might be correlated directly to one medication. There’s some companies out there that, for example, that focus on a panel that is only targeted towards behavioral health medications. 

But I think where the industry’s gone is kind of less precision on the exact drug that’s being targeted and more kind of broad panels that cover more medications, because the reality is, it’s a cheek swab, one time your genetics never change. So the results of this test are forever, right? There’s, there’s value in kind of understanding your genetic drug gene associations, as broad as possible, even if it isn’t incredibly impactful today for the one medication you’re on. So most of the panels that are being kind of embraced in the payer and plan world, are much broader panels that cover dozens and dozens of drugs, you not only find the information that’s helpful today for the medication the patient’s on today, but you’re ready for what’s tomorrow as well. 

There could be, you know, future medications that are covered by that pharmacogenomics test as well.  

Mike Stull (16:27) 

And then from the results of these tests, I mean, how do you, how is Optum thinking about how do you share that information? So, if I have multiple prescribers that I go to as a patient, I mean, is there a way to share that information across prescribers? So you’re not doing three, you know, two or three different tests, depending on the prescriber?  

Travis Baughn (16:54) 

Yeah, this is this is an area that we need to get better across in the United States on this is a healthcare ecosystem type of question for sure, in terms of how, you know, testing is shared amongst different providers. But what I will say is, labs make these pharmacogenomics reports available directly to patients, whether they’re facilitated through a PBM, through a health plan, or even through a provider, they’re available directly for patients. 

The unfortunate part is these reports are super complicated to read through. I’m talking dozens of pages with, you know, allele by allele results on whether you’re a poor metabolizer, rapid metabolizer, ultra metabolizer, and recommendations from the lab on how to respond to, you know, any drug gene associations that are noted. What I would encourage patients to do and what can be done is that report can be carried with you prescriber to prescriber. 

It’s not super fancy, but it can be right, you can take a printout to every prescriber you go to, you can give it to your pharmacist. And what I would like to see at some point is the connection point between the translated results of these pharmacogenomics tests, and claims processing systems at the PBM and health plan level. So we can actually connect the two. 

And when claims come through on medications that are covered by pharmacogenomics tests, we can intervene and say, “Hey, this patient has a pharmacogenomics test, maybe you should address the medication or not use this medication because it’s in conflict with the results of the PGX test”. That’s future state, we’re not there yet. But it’s where we should go.

Mike Stull (18:44) 

And are there certain prior authorization criteria that request or look for a pharmacogenomic test may not be the depression meds, but I’m sure there’s some more expensive medications or classes of medications where that might be the case.  

Travis Baughn (19:05) 

The prior authorization kind of aspect to pharmacogenomics is unique from a couple different angles. First and foremost, pharmacogenomics measures the body’s likelihood to respond to a medication or not respond to a medication. 

That doesn’t necessarily always translate into whether the medication upon any sort of adjustment might result in impacted kind of clinical outcomes for the patient. So pharmacogenomics, specifically the test that’s completed, for some areas of the healthcare world, do have impacts on prior authorization criteria, it would really depend, I guess, on an organization’s interest in embracing kind of disrupting that prescribing experience to guide towards pharmacogenomics testing to better inform the appropriate medication or dosage to be on. And I think ultimately, what this comes down to is whether the juice is worth the squeeze a in terms of completing that pharmacogenomics test, and whether there’s clinical benefit or financial benefit to that type of disruption in the prior authorization process. 

I’ll tell you, for most medications where, you know, you’re trying to avoid an adverse drug reaction that might be, you know, muscle cramping, or sleepiness, you know, perhaps that type of requirement and a prior authorization criteria just doesn’t quite make a lot of sense. But for other medications, probably the most famous one is Clopidogrel, lower cost medication, but certain populations just simply do not respond to the medication at all. And that medication is used to avoid strokes and heart attacks. 

That could make sense to require pharmacogenomics testing to ensure that, you know, the patient, you know, is appropriately put on the medication that is likely to have the most clinical benefit for them. And then the second piece to your question around higher cost medications, I think gets into the realm of more biomarker screenings. And that’s a little bit different than pharmacogenomics in terms of whether your disease has certain biomarker characteristics that are connected to the kind of clinical aspects of the medication. 

Those certainly are in a lot of prior authorization criteria, specifically on specialty medications. But it’s not the exact same as pharmacogenomics, which is measuring your body’s metabolizing pathways. So high similarity is between the two, but slightly different. 

Mike Stull (21:48) 

So one of the takeaways for employers would be, there’s a lot of nuance here. And, you know, a lot of times when I’ll read articles or look at conference talks geared towards employers, you know, it’s about embracing, you know, pharmacogenomics. But even, you know, making sure that we’re talking about the same thing is important and also understanding that there’s a lot of decision points within it, within the field of pharmacogenomics that we have to take into account. 

Are there other practical next steps for employers?  

Travis Baughn (22:23) 

You know, Mike, I touched on it a little bit ago, but I want to circle back around and focus on, to me, the most important piece to getting value from a pharmacogenomics type of program or benefit offering from the employer side. And it’s really around stratifying a population and only reaching out or prioritizing patients that are most likely to benefit from pharmacogenomics testing. Pharmacogenomics testing is not free, of course, it costs money. 

And that translates to value in a lot of different ways, as we mentioned earlier. And I think understanding program approaches that can connect members to pharmacogenomics testing, but really in a deliberate way that will benefit those patients, you know, with the highest likelihood possible, I guess, is I think, the next step that employers have to take towards pharmacogenomics. If you partner directly with a lab, they’re going to want to just, you know, pump out as much tests as possible, for the most part, right? It’s a volume game. 

In their world, the more labs that they complete, the more revenue that they generate. In our world, on the payer health plan, PBM side, it’s about value. It’s about actually doing testing that’s translating to either clinical value, or cost containment types of value. 

So I think it’s really about identifying those portions of the population that are likely to benefit, and marrying that up against the cost of providing pharmacogenomics tests to that population, and modeling out, you know, the anticipated kind of impact that can be seen by providing those tests to those patients.  

Mike Stull (24:17) 

Excellent. I think this is an absolutely fascinating area, in terms of where medicine is going. 

And so, I know we just scratched the surface today, but appreciate you, Travis, taking time to walk us through some of the baseline concepts, as it relates to things that employers should be thinking about. Are there any other good information sites that employers can go to? Does Optum have a website on pharmacogenomics? Or are there other good, reliable websites that you go to, to find more information?  

Travis Baughn (24:56) 

Yeah, I think we do have a landing page. I’m not sure if that landing page probably is educational in nature, more kind of program specific. 

There are a couple organizations that definitely are the leaders in terms of providing content and background on pharmacogenomics, what it is, how it works, and gets in that kind of a nerdy side, right, of actually the pathways and the drug gene associations. Those organizations, the first one is CPIC, Clinical Pharmacogenetics Implementation Consortium, I think is what they’re called. And then the other one is Pharm GKB. 

Both of those organizations are very, very well respected within the pharmacogenomics space, play a very critical role in kind of pioneering where we’re going with pharmacogenomics. And I’d recommend anybody who’s wanting to learn more to poke around on either of those organizations’ websites, because the reality is, the whole industry is kind of leaning on a lot of the pioneering that they’re doing within the space.  

Mike Stull (26:01) 

Excellent. 

We’ll put the links to those in the episode notes. Travis, thank you again for making time for us. Thanks for sharing your expertise with our audience. 

And we look forward to hopefully, at some point in the future, maybe we’ll have you back and talk more about this, again, fascinating topic.  

Travis Baughn (26:27) 

Absolutely. I appreciate the invite. 

And, you know, if you ever want to invite me back and talk much deeper, more nerdy talk on, you know, specifically the drug gene associations and examples of where this can actually make a meaningful impact on a drug-by-drug basis, I’m happy to come back. 

Mike Stull (26:43) 

Excellent. Thank you.  

Thanks, Travis. It’s exciting to hear the capabilities and advancements that can be made through pharmacogenetics. From eliminating waste to reducing expenses, I look forward to seeing the health improvements that will be made through this technology. 

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