Success with precision medicine: Key considerations

January 24, 2019

Countless physician groups are grappling with how best to introduce and leverage genomics in their practices.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

Countless physician groups are grappling with how best to introduce and leverage genomics in their practices. And with good reason as 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, with new discoveries about how these insights impact clinical decision-making circulating 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 in launching your program 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 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 (how individual patients process specific medications) would 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 she may not be at elevated risk for, 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 (ACOs) and shared savings programs. According to independent healthcare consultant Bryon Cipriani, one study 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 that physicians order. But even with outsourced genetic tests, most organizations are acutely aware of coverage because, if external labs are not reimbursed, they pass the cost on to the patients.

Unfortunately, reimbursement policy lags behind 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, states Cipriani, 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, he 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), intended to help health plans identify tests, determine coverage and determine reimbursement, is stabilizing payment in certain areas, although almost always at lower rates than what might have previously been paid.

Six steps to precision medicine

Within the context of this matrix of variables, six steps can help medical practices launch and grow a viable precision medicine program.

1. Understand your patient population.Who can benefit most from genomic testing? Do you have a large number of polypharmacy patients? Or individuals approaching the age where risk for certain conditions rises (e.g., coronary artery disease, cancer, etc.)? This information will help you understand if pharmacogenomics would deliver value, or if cancer genomics or germline testing for hereditable diseases is more appropriate (or both).

2. Evaluate where specific populations fit into various payer contracts you have in place. Are most covered in traditional fee-for-service agreements, or are many included in ACO or shared savings plans? Consider not only if you can deliver return on investment for the patient (i.e., lower personal costs, better care, etc.) but for the practice as well. Could precision medicine afford you the opportunity to take on more risk, because you can leverage genomics to better identify patients more likely to develop disease, intervene earlier, and target therapies more effectively?

3. Use the analysis generated by steps one and two to negotiate aggressively with payers. Determine which populations you likely can impact with precision medicine and work towards contracts that increase your revenue for effectively managing those patient populations while reducing payer costs.

4. Educate physicians and medical staff about precision medicineand your strategy to integrate it as the standard of care for specific patient populations.Ensure they understand the clinical value, as well as the business value, that genomics can deliver. In addition, develop educational materials to help patients understand how they can benefit from precision medicine and what to expect from their caregiver.

5. Begin your precision medicine program with the patients who were identified in step one as those where the greatest benefit can be realized.Integrate genomics testing with diagnostic and therapeutic care incrementally, so you can realize success before expanding into other patient groups.

6. Evaluate and assess technologies and solutions that can bring genomics data directly into the EHR workflow, allowing providers to use it in real-time clinical decision-making (e.g., should I prescribe antidepressant A or antidepressant B?). Typically, genomics results are reported on paper or scanned PDFs that cannot be clinically integrated within the patient context. And, all too often, test results have not been translated into clinical vocabulary that is meaningful and actionable for providers. New platforms are emerging that bridge the gap between the science of genomics and making the data useful at the point of care.

Industry thought leaders agree that genomics holds great potential to transform healthcare- from prevention to diagnosis to treatment. Patients are often ahead of their providers in understanding how genomics can help them stay healthier, and in highly competitive healthcare markets, providers cannot afford to be late adopters. By thinking strategically and equipping providers with critical support tools, practices can leverage the promise of precision medicine to improve current clinical practice-and begin to reap the benefits of better care and outcomes. 

Joel Diamond, MD, FAAP, is an adjunct associate professor of biomedical informatics at the University of Pittsburgh. He is a diplomat of the American Board of Family Practice and a fellow in the American Academy of Family Physicians. He cares for patients at Handelsman Family Practice in Pittsburgh and serves as Chief Medical Officer for 2bPrecise, LLC.