Know the Facts on Pharmacogenetic Testing
Workers’ comp payers seeking to reduce costs may want to consider pharmacogenetic testing for some injured workers. The escalation of information on PGT and its clinical uses are making the idea of personalized medicine closer to reality, according to experts.
The use of pharmacogenetic testing is increasingly being seen in many health care applications. Vanderbilt University, for example, has a program that uses prospective genetic testing to guide drug selection and dosing and lower patients’ risk of adverse drug reactions. A 2014 study of that program showed the vast majority of patients carry at least one pharmacogenetic variant, data are available at the point of care, and there is a substantial reduction in testing burden compared with a reactive strategy.
Other major medical institutions using PGT for pre-prescription testing include Mayo Clinic, University of Florida, Scripps Health, and St. Jude’s Hospital.
As the use of PGT expands into the workers’ comp space, there are a plethora of organizations offering the service.
“Get yourself educated,” said Maria Chianta, director of clinical strategy and programs at Millennium Health. “Challenge labs on why they offer what they offer. What is the evidence? What reporting would they have? Is the lab paying the doctor at all? If so, that’s a red flag.”
Speaking during the annual meeting of CompPharma, an association of pharmacy benefit managers, Chianta discussed the testing and how it can help clinicians make better decisions about prescribing medications.
“It started in 1959,” Chianta said. “The Pharmacogenetic era has been fueled by an explosion of scientific and clinical research that is only accelerating.”
In fact, there are now 138 medications that have PGT information included on Food and Drug Administration product labels. In workers’ comp, PGT can help identify genetic variations in metabolic enzymes to help medical providers avoid trial-and-error prescribing and identify causes of patient problems.
A 55-year-old female identified as Tammy was suffering from persistent low back pain following a spinal fusion with radiculopathy. She had a history of occasional alcohol use, no history of drug abuse/misuse or psychiatric illness, high cholesterol, and Type II diabetes.
She was taking a variety of medications, including extended release oxycodone, oxycodone immediate release, and gabapentin. Her husband had noticed she had increasing sedation.
The medical provider ruled out other disease states or conditions that could have impacted Tammy’s response to treatment. He discovered she had recently started a weight-loss program, which included an over-the-counter supplement.
“Urine drug testing and pharmacogenetic testing may be useful in determining potentially needed changes to Tammy’s therapy,” Chianta said.
In doing the PGT testing, clinicians determined Tammy was an “intermediate metabolizer” of the CYP2D6, an enzyme that was tested. The addition of a grapefruit extract supplement — part of her weight-loss program — resulted in inhibiting two clearance pathways, which “may increase the potential for side effects/toxicity due to accumulation of oxycodone,” Chianta explained. “Tammy’s CYP2D6 intermediate metabolizer status put her at an increased risk for medication interactions and accumulation of oxycodone.”
Genes and Medication
PGT can help identify how genetics impacts a drug’s response in a person’s body. “Patients with the same diagnosis may have substantially different responses to the same drug,” Chianta said. For example, they can have four possible responses to a medication:
- The drug is effective but toxic.
- The drug is not toxic but also not effective.
- The drug is not effective but is toxic.
- The drug is effective and not toxic.
A study of more than 1,100 patients tested for drug-gene interactions showed that “one in three cases of predicted major drug interactions was due to genetic variations in metabolism,” Chianta explained. “When you look at patients, there are very few people who don’t have a variation enzyme.”
Response to medication is highly variable. “Adverse drug reactions, poor therapeutic responses, and non-standard dosing are common,” Chianta said. “Inadequate treatment increases the risk of poor patient outcomes.”
According to research, adverse drug reactions affects one in five patients. Forty percent of adverse drug reactions are classified as serious, life threatening, or fatal. There are also increased costs associated with adverse drug reactions, including more visits to physicians and increased hospital stays.
“Pain and mental health treatments are among the medications most frequently causing ADRs,” Chianta said. “PGT may help clinicians identify patients at higher risk for ADR.”
The U.S. spends an average $300 billion on prescription medications annually, Chianta said. For every dollar spent, another dollar is spent on adverse outcomes of prescription medications.
Pharmacogenetic differences may impact a patient’s response and toxicity to opioids. According to studies, there is a nonresponder rate of 30 percent to 40 percent — even among effective opioid therapies.
Genetic variations in certain genes are associated with increased pain sensitivity and opioid dose requirements, as well as opioid metabolism and response.
“Clinically relevant variation is very common when measured across multiple genes,” Chianta explained. “More than 90 percent of patients receiving care in a specialty pain practice exhibited variant phenotypes in at least one enzyme important for metabolism of medication routinely used in this population.”
When used as a tool along with other medical cost containment measures, PGT can lead to lower costs and better outcomes, according to Chianta.
“PGT is another piece of information to better match medications to patients,” Chianta said. It can help “to move from a one-size-fits-all approach to personalized medicine to better anticipate results.”
Study ‘Raises Concerns’ About Unnecessary Drugs
Reforms addressing physician dispensing might need to target specific drugs in addition to prices, suggests a new study.
A review of workers’ comp claims in Florida points to evidence that physicians allowed to dispense medications prescribed unnecessarily strong opioids.
The Workers Compensation Research Institute looked at claims both pre- and post-reforms to curb physician dispensing in Florida. The results surprised the researchers.
“If the pre-ban strong opioids were necessary, researchers would expect that workers who received weaker physician-dispensed pain medications after the ban would later need strong opioids (that can be dispensed only at a pharmacy).
But only 2 percent of those with weaker physician-dispensed pain medications in the first six months after the ban received strong opioids at a pharmacy in the next six months,” the report said.
“This raises concerns that a significant proportion of pre-reform physician-dispensed strong opioids were not necessary, which means injured workers in Florida were put at greater risk for addiction, disability or work loss, and even death.”
The researchers looked at the prescribing behaviors of physicians after Florida banned physician dispensing of strong opioids.
They found no material increase in pharmacy-dispensed strong opioids but instead an increase in the rate of patients receiving physician-dispensed weaker pain medications — nonsteroidal anti-inflammatory medications such as ibuprofen.
The percentage receiving weaker opioids increased from 9.1 to 10.1 percent.
The study comes as policymakers in several states focus on the prices charged by physician dispensers compared to pharmacies for the same medications.
But increasingly there is speculation that economic incentives associated with physician dispensing lead to unnecessary medications prescribed for injured workers.
“When we compare pre- and post-reform prescribing practices, it appears that physician-dispensers not only reduced their dispensing of strong opioids but also reduced prescribing of strong opioids,” said Richard Victor, WCRI’s executive director.
“Since Florida has banned physician dispensing of strong opioids, the lessons of this study are relevant for the other states concerned about eliminating unnecessary costs in their system while protecting injured workers from unnecessary medical care.”
Diversifying Top Management in Workers’ Comp
The panel at the inaugural Women in Workers’ Compensation (WiWC) Forum. From left to right: Eileen Ramallo, Elaine Vega, Nina Smith-Garmon, Nancy Hamlet, Michelle Weatherson, Nanette de la Torre, Danielle Lisenbey.
Across the country, the business community is engaged in a robust conversation about women being under-represented among c-level positions.
Why aren’t more women breaking into upper management roles? Does gender bias still exist? And, perhaps more importantly, what can women and men do to add more diversity to top leadership ranks?
Elaine Vega and Nancy Hamlet, of Healthcare Solutions, the Duluth, Ga.-based health services provider to the workers’ compensation and auto liability/PIP markets, have discussed the issue between themselves many times over the years.
The duo agreed that starting an industry-wide conversation would be an effective start to addressing the challenge. After three years of internal discussions, the inaugural Women in Workers’ Compensation (WiWC) Forum became reality. Judging by the attendance, content and feedback, it was an auspicious, very successful, debut.
Specifically, Healthcare Solutions and LRP Publications teamed up at the National Workers’ compensation and Disability Conference (NWCDC), held Nov. 18-21, 2014 in Las Vegas, to present the first WiWC event focused on the development of women as leaders within the industry. The WiWC debut featured a keynote speaker, a panel discussion and a networking cocktail hour.
“We believe this is just the beginning for the WiWC organization,” said Hamlet, senior vice president of marketing, adding that the event’s main theme was the conversation regarding challenges that still exist for women in the workplace is “current, real … and relevant.”
Originally the forum was allocated a room to hold 150 people. Vega and Hamlet worried about the room being too large, so they asked LRP what the contingency would be to make the room smaller if they couldn’t fill it. They needn’t have worried, as more than 400 women, and some men as well, registered and attended, requiring an even larger room.
“Clearly, the topic is relevant and there was plenty to discuss,” said Vega, senior vice president of account management.
Hamlet explained that WiWC was formed to create an open forum to promote a strong sense of community and support for current and future female leaders in the workers’ compensation industry. Going forward, the WiWC forum will provide insight and ideas with opportunities for members to:
- Engage … with accomplished industry professionals and build lasting relationships.
- Enrich … their knowledge base with tactical insights from speakers and panelists.
- Explore … opportunities and challenges facing women leaders today.
- Encounter … senior executives’ perspectives on leadership.
- Examine … leadership strategies and how to effectively apply the strategies.
- Empower … themselves and others to achieve success and groundbreaking results.
At the inaugural event, keynote speaker Peggy Holtman, co-author of “Leading at the Edge: Leadership Lessons from the Extraordinary Saga of Shackleton’s Antarctic Expedition,” discussed how a seemingly unconnected historical event can offer critical lessons on leadership in the workplace, especially for women looking to move into top executive spots.
After Holtman’s talk, a panel discussion, moderated by Vega, offered the perspectives of five workers’ compensation industry executives on ways in which women can navigate past the glass ceiling. Panelists included Eileen Ramallo , EVP Healthcare Solutions; Danielle Lisenbey, CEO Broadspire; Nanette de la Torre, VP Zenith; Nina Smith-Garmon, EVP Mitchell International; and Michelle Weatherson, Director, Claims Medical and Regulatory Division, State Fund of Calif.
The panelists discussed a wide range of topics related to women in workers’ compensation. For example, one topic focused on the need to take the big risks when it comes to moving past workplace barriers. Other topics included the importance of women in higher positions serving as sponsors and advocates for younger, less experienced women; and the impact of industry consolidation on women’s careers and how to best manage that change. Another topic was how women could best master conflict and emotions in the workplace.
“What’s clear is conflict has to be managed; it will not go away. It will only get worse,” said Healthcare Solutions’ Ramallo. “It then can create other rifts that won’t necessarily be visible immediately, but can have a very large impact. You have to be able to understand what it is early on from another’s perspective, why the situation exists, and then encourage and try to resolve a conflict situation, whatever may be driving it.”
In the wake of the first WiWC Forum, Hamlet noted that while there are countless general reports showing that women have not yet achieved equal representation in top leadership positions in the workplace, studies deal with averages rather than individual stories. And while women must continue to look at the data and work toward closing the gap, hearing from accomplished women in the workers’ compensation industry at NWCDC drove home critical messages on a person level.
Today, Vega and Hamlet are looking to expand WiWC to make it “truly owned” by the industry. For example, they expect to recruit companies interested in becoming sponsors, forming an advisory council, creating a charter and discussing future possibilities for the organization on both the national and regional levels.
“Much remains to be done, but I have confidence that we will come together and make the organization stronger so that it prospers for years to come,” Hamlet said. “After all, it’s clear that our industry is filled with talented women who can make things happen!”
Vega added that WiWC has already received requests to live stream the event in the future, so it will examine the feasibility of that option in an effort to be even more inclusive.
“We have a shared vision for improving opportunities for current and future women leaders in workers’ compensation,” Vega said. “It doesn’t matter our gender or our title, it’s all about supporting the greater vision. As was said several times at the event, this is just the beginning. We hope more women and men will join us in this continued dialogue.”
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthcare Solutions. The editorial staff of Risk & Insurance had no role in its preparation.