AH077 - Rx Retro: An Approach to Safe & Effective Deprescribing, with Lauren Carroll, PharmD

Transcript

Lightly edited for clarity.‍

[00:27] Justin Venneri: Hello and thank you for listening to another episode of Astonishing Healthcare. This is Justin Venneri, your host and Senior Director of Communications at Capital Rx, and we have another clinical programs focused episode for you this week.  

Lauren Carroll is back in the studio with me today. She's a pharmacist on our team here and was a guest on our special episode for Women Pharmacist Day last year.

[00:48] Lauren Carroll, PharmD: Hey, Justin. Thank you for having me back. I am excited to be here.

[00:53] Justin Venneri: So that was a fun episode. I'll link that in the show notes, but for anyone who didn't listen to that, please spend a minute on your background and your path to Capital Rx and your role here.

[01:02] Lauren Carroll, PharmD: So as far as my background goes, I obtained my Doctor of Pharmacy degree from Auburn University Harrison School of Pharmacy. I then went on to complete a managed care PGY1 residency at Evolent Health, which is a company that supports health plans and providers with various administrative and clinical solutions.  

After my residency, I was hired on at that same company as a clinical pharmacist specializing in clinical analytics. In this role, I conducted telephonic outreach to patients as it relates to things like adherence and medication therapy management and gaps in care. I also built out both identification logic and reporting for our various clinical solutions. During this time, I did also obtain my board certification as an ambulatory care pharmacist.  

I have been at Capital Rx for almost two years now and I serve as a Senior Clinical Programs Manager. In this role, I work closely with our data and analytics teams to build out reporting across all of our clinical programs. I also oversee Rx Ally, which is our opioid safety program, Point of Sale Patient Safety Alerts, which is also known as our Concurrent Drug Utilization Review Program, and Rx Retro, which is also known as one of our retrospective drug utilization review programs. And this program focuses primarily on medication deprescribing.

[02:20] Justin Venneri: Yes, I love it. And clinical programs are definitely one of my favorite topics. And when I started to learn more about Rx Retro, I was pumped to get in touch with you and then set this up so that we could share all this info.  

So how about we just start off at a high level? What's deprescribing in the context of this program? Or if the definition of deprescribing is what it is, forgive this silly question to start out.

[02:42] Lauren Carroll, PharmD: Sure, yeah. Medication deprescribing is when, under the supervision of a healthcare provider, potentially inappropriate medications are stopped.

[02:51] Justin Venneri: Okay.

[02:51] Lauren Carroll, PharmD: Yeah. These medications, they either have risks that outweigh the benefits, are duplicative in nature, or are just no longer necessary.

[02:59] Justin Venneri: And in some ways, I know we've talked about this for other clinical programs where it's like, you start on something and you want to wean off of it. Is that really the same thing or different reasons for the quote, unquote, deprescribing?

[03:09] Lauren Carroll, PharmD: It is really important to kind of work with a healthcare provider when you're discontinuing medications. Certain medications do have specific instructions that have to be followed to help prevent withdrawal or other potential side effects. But the reason for, you know, discontinuing a medication could be that the medication is causing adverse events or drug interactions or is duplicative in nature. So, it could be any one of those things.

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[03:34] Justin Venneri: And how do we here at Capital Rx address deprescribing?

[03:38] Lauren Carroll, PharmD: So one of the ways is through our clinical program, Rx Retro. Rx Retro actually builds upon our existing patient safety alerts.  

So just for some background on what these alerts are and how they work, because that'll be important in understanding how Rx Retro works, these alerts work by notifying the dispensing pharmacist of a drug therapy concern at the point of sale. So, they are configured either as message only, which is an informational message that displays for the dispensing pharmacist, and it does not require override codes to be entered for the claim to pay.  

These claims could also be configured as what we call a soft reject, which actually stops the pharmacy claim from paying due to it having a drug therapy concern, unless the dispensing pharmacist reviews that alert and enters the appropriate codes to bypass the alert, which would then allow the claim to pay.

[04:26] Justin Venneri: Interesting. This is all happening in real time. If you picture just standing at the pharmacy counter, this could pop up as the pharmacist is working on your prescription.

[04:34] Lauren Carroll, PharmD: 100%. Yes. This is all happening in real time. So through Judi®, we're able to kind of leverage that technology to be right there at the point of sale, notifying that dispensing pharmacist of drug therapy concerns. So they're a crucial component before a patient gets their medication, part of the review that the dispensing pharmacist does to make sure that the medication is safe for the patient. So these alerts are essentially, you know, their goal is to aid that dispensing pharmacist and notifying them of any concerns before the patient gets the drug.  

But what some listeners may not know is that data shows that point of sale safety alerts are bypassed by the dispensing pharmacist up to 90% of the time. So despite having this point of sale alert in place, medications with potential drug therapy concerns are still getting to the patients for one reason or another. And that's really where Rx Retro comes in.  

So Rx Retro's goal is to improve the success rate of resolving these drug therapy concerns and ultimately deprescribing medications. So Rx Retro is going to take an additional step to notify the actual prescriber of the drug therapy concern when the dispensing pharmacist overrides these patient safety alerts or when the informational message is deployed at the point of sale.

[05:48] Justin Venneri: How does that work? I know from speaking with Jackie and Halls and Rx Smart Save, there are different levels of the program, different types of outreaches made to the pharmacy, to the providers. Is Rx Retro set up similarly?

[06:03] Lauren Carroll, PharmD: Yes, it certainly is.  

So Rx Retro has two levels. The first level is where we notify the prescriber of the deprescribing opportunity via fax. And then for level two, this is more of our high touch level of the program. Our actual Capital Rx pharmacists call prescribers to discuss the deprescribing opportunities. And if the prescriber agrees to deprescribe a medication, the Capital Rx pharmacist then calls the member to counsel them about the clinical concern, answer any questions they may have, and notify them that their prescriber will be reaching out with a deprescribing plan.

[06:41] Justin Venneri: Got it. And this might be a silly question too, but at what point, if you had to guess, do you think we'll ever get away from using a fax machine in healthcare in the United States?

[06:50] Lauren Carroll, PharmD: If anyone's gonna solve it, it's gonna be Capital Rx. I could tell you that.

[06:54] Justin Venneri: I hope so. This is crazy.

So the member journey comes up a lot. And it seems like this handheld level two for sure is handheld, and level one is somewhat sort of automated. But the member journey here, what's that like for a member? When Rx Retro kicks in? How is Judi leveraged? It sounds like it does help with reducing any potential friction between a provider worrying why the pharmacist might be intervening in the prescription and talking to the member. Can you talk a little bit about that dynamic?

[07:24] Lauren Carroll, PharmD: Sure. Yes, so our goal is to work collaboratively with physicians. So we are on the same team, and we want to make sure that ultimately the patient is getting the right drug and it is safe and effective. So that is our whole goal when we're reaching out to providers here.  

I want to give you an example, and I'll use GLP-1s since they are still a hot topic in the industry. And let me just walk you through exactly from start to finish, how Rx Retro works and how we kind of collaborate with the physicians.

[07:54] Justin Venneri: Awesome.

[07:55] Lauren Carroll, PharmD: So let's say in January a patient filled Ozempic for a 90-day supply at XYZ Pharmacy which was prescribed by their primary care doctor. And then let's say in February they go see their endocrinologist, and their endocrinologist prescribes Mounjaro. And let's say the patient fills it at a different pharmacy, maybe ABC Pharmacy. So we have here two different physicians prescribing GLP-1s and the patient's filling them at different pharmacies. So you can see how this may get missed, right, in healthcare industry.

[08:30] Justin Venneri: Especially with everything being disconnected the way it is, yeah.

[08:32] Lauren Carroll, PharmD: 100%. So thanks to Judi technology and our Patient Safety Alert program, the Mounjaro prescription soft rejects at the point of sale with a drug therapy concern of duplication of therapy due to the previously filled Ozempic. So even though the patient filled at two different pharmacies, we as the pharmacy benefits manager can see that they tried to process both of those GLP-1s through their pharmacy benefit. So we're able to kind of reject that claim and stop it at the point of sale.  

Now let's say the dispensing pharmacist decides to bypass that duplication of therapy alert with an appropriate override code allowing that claim to pay. Let's say she spoke to the patient who was adamant that they just saw their endocrinologist, they need this medication, so she went ahead and filled it. What the member doesn't realize is that these drugs are in the same drug class. So the member is proceeding to take both GLP-1s, Ozempic and Manjaro. Through Judi and advanced analytics, Rx Retro is actually able to identify that this member has a potential drug therapy opportunity since the Mounjaro fill received that duplication of therapy rejection and was overridden at the point of sale.

[09:46] Justin Venneri: So we know.

[09:48] Lauren Carroll, PharmD: Yeah, we know. We're able to kind of tell that's been overridden. And we then proceed to send a fax to the endocrinologist who prescribed the Mounjaro. Let's say this health plan elected Rx Retro Level 2. After that fax is sent, telephonic outreach would also be made by a Capital Rx pharmacist. And they would call the endocrinologist that prescribed Mounjaro and. And then they would also call the primary care physician that prescribed Ozempic if necessary.  

Let's say that they talk to both physicians, and the primary care physician actually agrees to discontinue the Ozempic so that the endocrinologist, who is a specialist, can manage the patient's diabetes as they see fit. Since that prescriber agreed to discontinue the Ozempic, the pharmacist would then call the member as well. Let's say during that call, the member says they've been experiencing a lot of side effects. They've had abdominal pain, nausea, vomiting. They were thinking about going to the ER if it didn't resolve because they weren't sure why that was happening. Our pharmacist is there to kind of counsel the patient and say, you know, these symptoms are likely due to this duplication of therapy between the Ozempic and Mounjaro, and kind of let them know your primary care physician will be reaching out to discuss a deprescribing plan for Ozempic. These are the risks that can happen when you take two medications in the same drug class.  

So ultimately, a member's adverse events are resolved. We've prevented a potential ER visit, and we've also been able to discontinue an expensive duplicative medication.

[11:17] Justin Venneri: Is this a hypothetical example that may be an actual representative interaction between our Capital Rx pharmacist team and providers and a patient?

[11:28] Lauren Carroll, PharmD: Exactly, Exactly. But this is something that that can and does occur. And we often see, you know, especially with multiple physicians managing a patient's care, this is something that easily happens, unfortunately. And we kind of have the tools to jump in and help resolve this before, like I said, an ER visit occurs.

[11:46] Justin Venneri: Manually connecting the dots until we can technologically connect all the dots.

[11:53] Lauren Carroll, PharmD: Well, we do use a lot of technology to help us here, so I have to give a big shout out to Judi because we couldn't do it without that technology.

[12:01] Justin Venneri: The GLP-1s example is a great example because I think we've seen that a lot, unfortunately, over the last I'd say 12 to 18 months. We see that when we're doing reprices for prospective clients during the RFP process. And just a lot of times in data that we're evaluating for people to just be helpful, it pops up and we're like, wow, like, why does this member have these prescriptions? You realize they shouldn't, right? Not just from a monetary perspective, but from a safety perspective. So it's good that we have multiple ways to catch this.  

Are there any other specific clinical areas that Rx Retro targets that you can share?

[12:36] Lauren Carroll, PharmD: Yeah. So in addition to duplication of therapy, which is kind of the example we just reviewed, we focus on a number of other clinical areas. We focus on the use of potentially harmful medications in certain disease states like asthma, COPD, heart failure and dementia. We focused on potentially inappropriate medications that are being used in the elderly and children. We focused on situations where medications are potentially being overused. And we really chose to focus on these areas either because they are a quality measure or because data showed a high incidence of these clinical concerns actually occurring in practice.

[13:18] Justin Venneri: And by being a quality measure, is it more for, you know, Star Ratings? Is this more for government programs or is this program potentially available to commercial plans as well?

[13:27] Lauren Carroll, PharmD: Yes, this program is available to both government and commercial plans, but we do focus on things that are quality measures, and that's important to most health plans. I mean, when health plans focus on medication deprescribing in their patient populations, there are many benefits. And one of those is improving those quality metrics. So some of the areas that we focus on in Rx Retro are in fact Star, PQA or HEDIS measures.

[13:54] Justin Venneri: Cool. Okay, so how could deep prescribing benefit a member, aside from avoiding prolonged exposure to like, high risk drugs or overuse, helping their pocketbook, so to speak, too?

[14:04] Lauren Carroll, PharmD: Sure, sure. One thing I want to touch on is just how common polypharmacy is, and it really affects more people than you may think.  

So polypharmacy is commonly defined as the regular use of five or more medications. So think about your parents or grandparents, like many of them would easily fit into this category. And actually the CDC did a study on this and found that one in five Americans between the ages of 40 and 80 use at least five prescription drugs regularly. And this number increases if you just look at patients 65 and older. So polypharmacy is a common thing that's happening. And just plain and simple, the more medications you consistently take, the higher the chance you're going to have a drug Interaction, an adverse drug reaction, or a duplication of therapy.  

So as you may guess, there's a lot of benefits when patients discontinue these potentially inappropriate medications. You mentioned, they'll save money, yes. If you're filling fewer prescriptions, that is a benefit. But you're also going to reduce the chance of side effects and drug interactions, which will often lead to doctor and hospital visits, so you're preventing those. You're also helping the patient reduce their pill burden or the total number of tablets or injections that they take each day, which is a huge benefit to patients. So helping them be more adherent to the drugs that actually are benefiting them.

[15:26] Justin Venneri: And the benefits of the health plan government programs are commercial. I mean, we talked about a couple. Obviously the quality measures are an important one, right?

[15:33] Lauren Carroll, PharmD: Yes, quality measures are an important one. So like I said, you know, some of the things that we focus on in Rx Retro are those Star, PQA, or HEDIS measures. So for example, like the use of multiple anticholinergics in the elderly, that's a PQA measure and is actually on track to be an official Star measure. We also focus on things like antipsychotic use in patients with dementia, which is a PQA and HEDIS measure and is also a Star displays measure.  

So measures like that are things we try to focus on, and then as I mentioned before, other clinical areas that we just see a high volume of these clinical concerns and we want to make sure we address them as well.

[16:10] Justin Venneri: All right, so the Rx Retro program is an example of a pharmacist led program. Can you share a little bit more about the interaction and what we think PharmD-led deprescribing does for the system and why it can be so effective?

[16:24] Lauren Carroll, PharmD: Sure. Rx Retro is certainly a pharmacist led program. The initiatives that we chose to focus on, the identification logic for Rx Retro, these were all developed entirely in-house by Capital Rx pharmacists. And not only that, the pharmacists that are reaching out to the prescriber and the patient, those are Capital Rx pharmacists as well. So definitely pharmacist led.  

And there are a number of published studies that show that pharmacist involvement in patient care leads to better outcomes. So we know this. But let me give you some examples of why I think deprescribing programs like Rx Retro are effective.  

We are uniquely positioned to have that visibility into all the pharmacy claims that are billed through the patient's insurance. So this allows us to bridge those gaps that exist in the healthcare system. And our pharmacist can identify various clinical concerns that physicians and retail pharmacists may not be equipped with the data to be able to do so.  

Additionally, pharmacists are the medication experts. So we can review a patient's drug therapy regimen through a little bit of a different lens. And we're really focused on those potential drug therapy problems and how we can recommend solutions to prescribers and work collaboratively to get the patients on the right medication and the safest medication for them.  

And I'll give you one last plug for pharmacists. We are also one of the most trusted and accessible healthcare providers in the industry, and we are highly trained to work collaboratively with physicians, nurses, and also patients.

[17:55] Justin Venneri: Yeah, and I prefer going to my independent pharmacy around the corner oftentimes too. I mean, it's usually a pleasant interaction and it's easy enough. So I think that's a long-standing truth that people generally trust their pharmacists and nurses, I think as well, right?

[18:12] Lauren Carroll, PharmD: Yes, a hundred percent. And I'm so glad to hear that. I'm glad you've had a good experience with your pharmacist.

[18:18] Justin Venneri: So, last question. Thanks, Lauren, so much for taking the time to share your background and the details on Rx Retro with us, and the point of the program.  

What's the most astonishing or surprising thing that you've seen since launching Rx Retro? I'll just keep it super specific to this topic, and of course have to throw in the compliance layer that's safe, of course.

[18:35] Lauren Carroll, PharmD: Certainly. So the most astonishing thing I have seen is just how many members Rx Retro is identifying for deprescribing opportunities on a monthly basis. This just confirms that our program is truly focused on pertinent clinical issues and that deprescribing is something that the healthcare industry should continue to focus on.

[18:58] Justin Venneri: Is there any debate about that at this point, just out of curiosity?

[19:03] Lauren Carroll, PharmD: I don't think so. I don't think there's a debate. But it is surprising to see how often these medications are still getting to the patient, despite all the potential checks and balances in place. So it just further confirms that physicians, pharmacists, nurses, everyone as a part of the healthcare team has a role in medication deprescribing. And it's still something that should be top of mind when you're working with your patients.

[19:26] Justin Venneri: All right. Lauren, thank you so much for joining us on the show today. You have a great rest of your day, and I look forward to staying in touch.

[19:32] Lauren Carroll, PharmD: Thanks so much Justin. It was a pleasure.

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