Countless physician groups are grappling with how best to introduce and leverage genomics in their practices.
With good reason. Precision medicine appears to be an unstoppable force that could revolutionize how physicians diagnose and treat patients.
The science of genomics has advanced at a rapid pace, and new discoveries about how these insights impact clinical decision-making are circulated almost weekly. Consumer demand is rising, thanks to regulatory approval for direct-to-consumer genetic testing and resulting media coverage.
In my own practice, more and more patients come to office visits with questions about how genomics could help identify their risk for disease, how this data could guide wellness, prevention and screening activities, and if we should adjust medications and other therapies based on their genomic profile.
So, how do you get started?
A business case for precision medicine
The most critical step is understanding what value precision medicine brings to your practice, and where it can have greatest impact from both a clinical and business perspective.
Consider how genomics can improve patient care:
When sharing family history during her initial visit, 34-year-old Emily reported incidents of breast cancer, colon cancer, high blood pressure and clinical depression within the past two generations. Genomic testing can help her physician identify which diseases pose a genuine risk for Emily – driving subsequent wellness activities and preventive care, and determining which tests and screening procedures should be ordered (and when) as she ages.
An avid bicyclist, Carlos recently suffered multiple fractures to his left wrist after a fall. Pharmacogenomics (PGx) testing would enable his provider to identify pain killers that Carlos metabolizes well, avoiding trial-and-error prescription and dosing delays while accelerating physical therapy and rehabilitation.
The medical benefits in both these examples are obvious. Emily’s physician can relieve her worries by learning which genetic variants she has inherited–and which she has not. Rather than conducting unnecessary or early screening for conditions for which she may not be at elevated risk, her physician reduces unnecessary costs and the possibility of associated side effects or complications.
Likewise, if his physician discovers the most effective drug immediately, Carlos has a shorter length of stay (if hospitalized) and fewer follow-up visits for medication adjustments. Plus, he feels less pain, heals faster and gets back to a higher quality of life sooner.
The net-net: lower cost of care and better outcomes faster. This translates not only into happy patients and higher satisfaction ratings, but also improved quality scores and a healthy bottom line for practices participating in accountable care organizations and shared savings programs.
According to independent healthcare consultant Bryon Cipriani, one study of 1,000 subjects has shown that practices can save $1,100-1,600 per patient per year when genomic testing is done.
The reimbursement landscape
Unless a practice has its own genetic testing lab, it will not bear the cost of processing and analyzing genomic tests physicians order. But even if they outsource genetic tests, most organizations are acutely aware of coverage because, if external labs are not reimbursed, they pass the cost on to the practice’s patients.
Unfortunately, reimbursement policy lags clinical practice when it comes to precision medicine – and payment varies wildly from state to state and test to test. Medicare coverage is advancing most rapidly, Cipriani says, with 80 percent of carriers covering specific pharmacogenomics testing such as behavioral health and pain panels (if appropriate ICD-10 codes are reported, supported by required documentation.)
Likewise, genomics tests may be reimbursed to identify disease risk and hereditable conditions (e.g., BRCA 1 and 2 or familial hypercholesterolemia). Medicaid plans also often provide coverage for specific tests, and may offer the best reimbursement, especially in areas where opioid addiction and behavioral health challenges are acute.
Commercial plans are less predictable, Cipriani adds. Some payers offer a flat fee, often a few hundred dollars, while others reimburse testing on a case by case basis–with payments for the same diagnostic codes ranging from just a few dollars to thousands. The advent and spread of Molecular Diagnostic Services (MolDX) is stabilizing payment in certain areas, although almost always at lower rates than what might have previously been paid.