Guest Interview: How prescription checkups can work on the ground

In the past decade, prescribing multiple medications to individual patients (called “polypharmacy” in scientific literature) has reached epidemic proportions. While many people benefit from taking multiple drugs to manage their chronic illnesses, each additional drug one takes increases the risk of suffering a serious side effect. As prescriptions have grown unchecked, millions of people have been put at risk of “medication overload,” or harmful polypharmacy. An estimated ten million older Americans in the US suffer from an adverse drug event each year. 

The Lown Institute identified “prescription checkups” – medication reviews that give patients and clinicians opportunities to deprescribe (stop or reduce the dose of a medication) appropriately – as a necessary intervention for reducing harmful polypharmacy. For prescription checkups to become mainstream, there is a need for public and commercial health insurers to make them a regular benefit for patients. 

One pharmacy benefit manager has already taken the lead on providing prescription checkups to members at risk of medication overload. Optum Rx is a pharmacy care services company that manages pharmacy benefits for clients including health plans, employers, unions and government entities. Their new prescription checkup program aims to keep members safe and healthy while reducing costs associated with drugs that are no longer providing benefit.  

I asked Sumit Dutta, MD, Chief Medical Officer at Optum Rx, some questions to find out how their program is working on the ground.

What is Optum Rx? How did you get involved in taking action against harmful polypharmacy?

Dr. Dutta: Optum Rx helps more than 60 million people achieve better health outcomes and lower costs through innovative prescription drug benefits, clinical programs, specialty services, and consumer-oriented solutions. My team of pharmacists and pharmacy technicians help people every day learn how to take their medications, avoid harmful drug interactions, and manage their chronic conditions. 

We have been hearing from our clients, including employers and health plans, about the importance of complex and high-cost member management. Included within that realm is polypharmacy, also known as the use of five or more chronic medications at one time. To understand more, we leveraged our data capabilities to efficiently identify opportunities to address medication overload – medications that are causing harm or are no longer providing benefit. Our systems look for certain medications, or combinations of medicines that are known to increase adverse events.

When we took a closer look, we identified potential medication overload in 7 to 12% of Commercial plan members. This was concerning because unnecessary medication use leads to waste and increases one’s risk of harm from the medications they are using. In response, we developed the Optum Rx Polypharmacy Value Management Program (PVMP), which provides prescription checkups to help ensure people are benefiting from their medication and minimizing risk. The program is available for employers or plan sponsors to adopt and ultimately helps members take more ownership of their own health, reduces risks associated with clinically unnecessary or unwarranted treatment, and potentially lowers medication costs.

Can you tell us more about this program, and how you involved pharmacists, doctors and members in the process?

We first use an algorithm to identify people who have a high risk of experiencing medication overload and are taking medications that could potentially be deprescribed. We found a number of people were looking to simplify their medications. In fact, 25% of the people we offered a prescription checkup participated in the consultation.   

Deprescribing patient story

Nick is a middle-aged patient who had trouble sleeping and was prescribed a common sleeping medication. He started experiencing sleep walking episodes – a serious and dangerous adverse effect from certain sleeping medications. Even though a boxed warning outlined the dangers of potential serious injuries or deaths from complex sleep behaviors, Nick was unaware of the high risk or the option to switch his medication until he spoke with an Optum Rx pharmacist as part of his prescription check-up. Through this targeted approach, the pharmacist worked with Nick’s provider to change the medication to fit his needs and lower the possibility of future safety risks. Nick is now on a medication that is right for him and his lifestyle.

Once identified as someone who may benefit from a prescription checkup, a person receives a letter, voicemail, or phone call that informs them about this free service. An Optum Rx pharmacist performs a comprehensive medication review and evaluates their response to each medication through a structured assessment. That may sound complex, but it really just involves asking patients important questions about each medication such as: Are you benefitting from this medication? Are you experiencing side effects? This shared decision process helps to identify safety concerns that would otherwise go unnoticed and identifies the medications that have the best chance for successful deprescribing.

Pharmacists also look for utilization patterns and combinations that are commonly associated with risky and potentially harmful polypharmacy. For example, pharmacists look for prescribing cascades where one drug is being used to treat the adverse effects from another (instead of stopping or changing the drug causing the problem).

The next step is to contact the primary care provider. With the person’s agreement, the pharmacist will reach out to the provider to share the results of the prescription checkup, including drugs they identified as good candidates for deprescribing. The provider then determines if it is clinically appropriate to stop, adjust or switch medications – or they might follow up with the patient to further discuss their medication regimen. In our prescription checkup pilot, 40% of providers adjusted medications following outreach from pharmacists.

Each person who participates in the prescription checkup also receives a Medication Action Plan and education about how to avoid harmful and wasteful polypharmacy.

What are some steps people can take to manage multiple medications safely?

During the prescription checkup, we give members education about the harms and waste associated with medication overload, as well as a list of questions they should ask their provider every time they receive a new prescription.

Keeping a full medication list on hand and updating it as prescriptions change helps people track and manage their medications too. Including the date the medication was prescribed and what it was originally prescribed to treat can be incredibly helpful. People may not know that simplifying or reducing their medications is an option; they should speak with their healthcare providers if they believe they are using too many medications or are experiencing adverse effects.

Post-checkup patient education sheet, OptumRx 2020

What have the results of the program looked like? How did participants react?

The goal of the program is to address medication overload and lower the risks and costs associated with clinically unnecessary or unwarranted treatment to enable people to lead a healthy life. So far, the results we have seen are encouraging: 25% of people offered a prescription check-up participated in the consultation and 40% of their providers adjusted medications following pharmacist outreach.

People reported they felt comfortable talking with our pharmacists about their medication experience and were more empowered and knowledgeable about what to share with their providers. Many participants proactively followed up with their provider directly following the consultation. What’s very clear is that many people are interested in simplifying their treatment and using less medications when appropriate and if their doctors agree.