David 0:00

A concept first envisioned way back in 1959 and first used just 19 years ago is now poised to make a quantum change that may revolutionize an entire part of how medicine is practiced at the consumer level. What is it and what could it impact? We'll find out on this episode of Shift Shapers.

SPEAKER_01 0:23

This is the Shift Shapers Podcast, connecting benefits advisors with thought leaders and entrepreneurs who are shaping the shifts in the industry. And now, here's your host, David Saltzman.

David 0:37

And help us talk about that way back technology that's going to revolutionize today, tomorrow, and the day after we've invited Nick Glimcher. Nick is CEO of Blue Jeans Labs. That's genes with a G. And his firm is at the tip of the spear of this 64-year-old concept known as pharmacogenetic or pharmacogenomic testing. We'll just call it PGX for the purposes of the interview. Welcome, Nick. Hey, David. Thanks for having me. How are you doing today? I'm doing well. It's our pleasure. Tell us a little bit about your journey. How do you get to be doing what you're doing?

SPEAKER_03 1:07

Well, we own laboratories, and when COVID started, everyone was super excited about the amount of COVID testing that was coming in. But we saw a different opportunity. We saw the opportunity to expand our offering set, and we leaned towards antimicrobial stewardship to start and medication adherence programming finish thereafter. We had been running pharmacogenetics for quite some time, but we realized that there was a critical flaw in the process. The data itself doesn't fit in the clinical workflow. So we looked to establish solutions to allow providers to utilize this key information in prescribing to patients.

David 1:47

To start with, give us a level set, give us a couple of examples. I know a couple of things that you talk about frequently is one widely used drug is Plavics.

SPEAKER_03 1:56

Yeah, so there are four different types of metabolizers. There's normal, which means you can take the drug just fine. There's intermediate, which means you can take this the drug, you can get to a therapeutic range, probably not the best drug for you. Then there's poor metabolizers and ultra-rapid metabolizers. When we talk about plavics, 28% of the US population is what's considered to be an ultra-rapid metabolizer of plavics. If you're an ultra-rapid metabolizer of plavics, you were eight and a half times more likely to have a bleed event. If you were stinted and given plavics, probably the best case scenario for you is to be re-stinted within the seven to ten days. And these things are avoidable complications that can be addressed with the application of pharmacogenetics.

David 2:41

There's another example that I know you use frequently is the OPRM gene. What is that and how does that factor in?

SPEAKER_03 2:47

Well, OPRM one has to do with the way that people metabolize and respond to opiates. So again, 20% of the US population here, regardless of sex or ethnicity. And if you have this mutation, low affinity opiates like oxycodin, by example, they don't work very well for you. You'll have to take a lot of oxycodin to get the pain relief that you're you're actually looking for. Conversely, when you convert to a high affinity opiate like fentanyl, which we're hearing in the news all the time, the conversion tables don't work. And you were 91 times more likely to overdose. And also OPRM1 is a key indicator of the patients that are going to tend towards addiction. So as we look at substance abuse and addiction issues in America, this is absolutely a gene that we should be looking at to put patients in categories at risk.

David 3:42

You just use two examples, one of which is medical, one of which goes to mental and nervous conditions. And there's a huge problem on both sides of that issue. I don't think that most people understand that they may know the drug they're taking, but they don't know how efficacious it will be. And, you know, some people could be taking, we'll go back to Plavvix, some people could be taking Plavics and it's not doing them any good at all. And point of fact, their disease is continuing to progress and they think they're doing the right thing. And truth be told, their doc may think they're doing the right thing, but they're not getting any better. They're getting worse. Why can't we know up front which is the exact right drug for me? I mean, I'm unique. My genetic makeup is unique. Is it possible today, using the technology that you guys are using and your labs are using, for me to know up front, hey, you know, Plavix isn't the right drug or oxycodin isn't the right drug for me, but this one is.

SPEAKER_03 4:40

Yeah, absolutely. I mean, 95% of the intervariability between how patients react to the same drug has been determined to be, you know, by your genetics. So we live in a practice of medicine society. So they're going to say, hey, try this drug. If it doesn't work, come back. Well, we have the opportunity to be involved in precision medicine. It just has to be formatted so that the providers themselves can actually use this information appropriately and efficiently within practice.

David 5:13

So from a practical standpoint, from a member standpoint, if you will, on a plan, first of all, do plans pay for this?

SPEAKER_03 5:20

Some plans do, some plans don't. I think that there have been a lot of issues with genetic testing overall that have led to concerns of the payers. Number one is like a lot of lab tests out there, there was tremendous overutilization in the beginning, and there was lack of the ability to apply the information. So payers have somewhat limited the opportunity for patients. So they have to have certain diagnoses, certain medications to qualify for this type of testing. But more importantly, what we're trying to do is educate the payers, educate state and federal government, healthcare organizations, that there is a way to apply this information. And it will not only improve clinical outcome, but it will reduce cost. And as we look at cost reduction in an inflationary environment right now, in a potentially difficult economic environment for the United States, these are the things we really have to look at when we look about healthcare costs.

David 6:22

So you could impact both cost and patient satisfaction and patient health long term. I presume it's a simple test, right? How exactly does it work? Give me the basic man-on-the-street explanation of how this all come all these pieces come together.

SPEAKER_03 6:36

Yeah, it's uh basically a buccal swab of the cheek, very much like we've been sitting in a COVID environment for three years. It looks just like a COVID swab, except you don't stick it up your nose. You just rub it against your cheek. We're going to collect DNA. And the great thing about it is we don't have any weather-based risks or shipping-based risks related to the collection of the specimen at all. The testing process takes typically about seven to ten days for the results to come back. And the great thing about what we do is we help make that interpretation of the data, which is normally very complicated, very simplified, so it can be applied very easily.

David 7:17

So if I'm the patient and I do a swab, do I get results back? Do they go to my doctor? Do we share them? How does that part of it work? So we do the cheek swab, we get the analysis done in your lab, then what happens?

SPEAKER_03 7:32

Well, you know, it somewhat depends on how the patient comes to us. So in many instances, we are working on behalf of the payer, on behalf of the self-insured employer, on behalf of the ACO, where they're actually doing patient selection. In that instance, yes, the patient would get a direct copy of the result. And in the instance where we are working directly with a provider group, the provider is going to do a diagnostic test order, much like they would do a blood test order or an infectious disease test order. And that would go to a cloud-based portal for the provider, and then the provider would share those results with the patient.

David 8:11

So we'll go back. We'll keep using Plavix as an example because it's so pervasive in society. If a doctor says to me, I think that we need to prescribe Plavix for you, would I say, hey, check the database. I've had a gene test done, or would the provider know to do that? How does that piece actually work where the rubber meets the road?

SPEAKER_03 8:30

I mean, that's such a great comment. So I'm part of the 28% that is an ultra rapid metabolizer of Plavix. If I go to my doctor and he prescribes Plavix, he's not the amazing Creskin. He has no idea. He can't tell you because my eyes are blue that Plavix won't work for me. If you have a genetic test or a PGX test to be more specific, yes, you could as a patient bring that up. Truth be told, most patients aren't strong enough with their providers to sort of challenge them, if you will. And part of what we do with our system is it is a system-wide integration, either at the EMR or PBM levels, that is alert, automated alert-based, that doesn't require the doctor to do additional work. If the doctor forgets to check a test that's once in a lifetime, by the way, it's not as if we're doing this test every time we were symptomatic. So it is easy for the provider to forget. But with this alert system, it tells them, much like if the patient has an allergy, don't prescribe this, much like if the patient is taking other drugs that don't mix well with that particular drug set, please change the med. Very similar concept in practice.

David 9:43

Are there also implications for over-the-counter drugs?

SPEAKER_03 9:46

Absolutely. About 80% of the medications that are available in the United States have some genetic impact to them. And that's the nice thing about what we do with our software is we look at the entire U.S. pharmacopoeia, not just a certain set of popularly prescribed drugs.

David 10:04

So you and I are clearly different generations. There's a lot of boomers out there, and a lot of them have multiple chronic conditions and are taking multiple drugs. And those drugs sometimes have interactions, and maybe, you know, provider A, maybe my cardiologist doesn't tell my pulmonologist while my other ologists are prescribing for me. How does that help in that kind of a situation?

SPEAKER_03 10:26

It's a great statement. You know, a pharmacy report is only going to tell you so much as that the patient picked up the drug, not that he's taking the drug per se. But what it's going to do is it's going to help save time. Okay. Or because if the patient's drug set doesn't work and we know it doesn't work, we can make the appropriate choice day one. You know, this isn't holds true in behavioral health really, really strong, because in behavioral health, you a lot of times you're dealing with trial drugs. You're like, oh, I'm depressed. Well, I'm going to prescribe you ProZac because your hair is blonde, and I'm going to do Lexapro for you because you have one ear that's this way and one ear that's that way. Well, instead we can say, hey, neither of those drugs work. In fact, SSRIs as a whole, you can't respond to. So let's look at something like Abilify, by example, and we can really save the time of that is wasted and the potential complications that are that the patients are exposed to by getting the incorrect medication.

David 11:31

Do you foresee a time in the near future where every drug will work properly the first time it's prescribed for somebody?

SPEAKER_03 11:39

Well, altruistically, we hope that what we're doing that is going to have a major impact. But we also have to be realistic. When we are working with the payers or self-insured employer groups and what have you, the test itself has a cost and they are looking for returns on their investments. And so the patients that are being targeted for this type of testing are high-risk, high utilizing patients. And so that's where we start. We start with that particular group. So, no, I don't think that we will impact every script that is written in the United States. But I do think what we will do is we have a significant impact on high-risk, high utilization patients that are costing the system significant amounts of money and essentially making their lives better by virtue of eliminating unnecessary medicines or making sure that the medicines that they are taking are actually appropriate and work for them.

David 12:39

We've got a couple of minutes left. And I think the last question that may end up being a challenge for some people being willing to take the test is you know, everybody has these conspiracy theories in their heads, and oh my gosh, somebody's going to have my genetic information and they're going to do something evil or discriminate against me in some way or another. How do you overcome that objection at the patient level?

SPEAKER_03 13:01

Well, I mean, the first thing I would start by saying somewhat facetiously is we're not 23 and me. This is a high complexity medical test. We're looking at genes that impact your CIPISO SIMES and response markers. I'm not 100% sure how could this could be used legitimately as any sort in any sort of discriminatory method because it is not as if we are suggesting that the patient not re-prescribed a medication or a drug. We're saying we're not going to prescribe this drug. And it benefits both the patient, the provider, and the payer from the perspective is the payer is going to reduce exposure and cost. The provider is going to effectively be in a better position to take care of patient and make sure that the patient avoids potentially avoidable complications. And then lastly, for the patient, if this is precision medicine. This isn't, you know, we're going to pull a rabbit out of the hat and see if it works. We can actually do this. We can actually tell you day one, this medication doesn't work. And we talk about things like, you know, behavioral health and stuff like Prozac, and people don't get concerned. But what if we're talking about an experimental chemotherapy and you're in stage, you know, four, you have stage four cancer? Well, that would be something serious. You don't want to take the risk of doing a six-month trial on something we could tell you hypothetically that doesn't work for you day one. So, you know, across the spectrum, we can have major impact. And I think that that far outweighs any conspiracy theories that might be out there.

David 14:40

And that's a great place to end our conversation today. But we do hope you come back as this gains more traction and becomes more pervasive. Nick Glimmer, CEO of Blue Jeans Labs. Nick, thanks so much for sharing your expertise with the audience.

SPEAKER_03 14:51

Yeah, thanks for having me, David. Really appreciate it.

Announcer 14:55

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