At Priority Health in Michigan, about 24 patients with advanced cancers have gotten comprehensive genomic profiles of tumors since the managed care plan launched a testing program in October 2014. The aim? To give more information to physicians trying to help patients understand treatment options.
The cost? The genome tests cost $4,000 to $5,000, whereas it costs $7,000 to $15,000 per month for one drug therapy—and multiple drugs may be used, says John Fox, MD, Priority Health’s associate vice president of medical affairs. “We think there’s an unmet need, especially for rare, aggressive tumors...The goal is to get patients the optimal therapy the first time,” he says.
It’s been almost a dozen years since the Human Genome Project finished sequencing and mapping all human genes, allowing a first-time look at a person’s entire genetic blueprint. Since then, consensus is building on the promise of genetic testing and other technological advances to help individualize testing, prevention and treatment for better outcomes. But the road is bumpy as payers, health systems, hospitals and physicians in a fragmented delivery system face an overwhelming array of information to discuss with patients and act upon—if it is clinically actionable at all.
The aim of precision medicine—a term derided by some healthcare stakeholders as sounding more like marketing hype than science—is to develop more accurate diagnostic tools and therapies to help predict what will work best for the individual instead of using a one-size-fits-all approach.
That means not only performing genetic profiling to help treat cancers and other conditions, but also combining molecular information with environmental, behavioral and other data. Then comes interpretation and finding ways to overcome logistical and cost challenges—and handling issues ranging from patient privacy and consent to coding, electronic health records (EHRs) and coverage—to create a framework that allows its integration into healthcare delivery.
“I think it’s a real challenge for managed healthcare,” says Michael Millenson, president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University. “In some cases, this can be curative of very deadly diseases, and how do you say, ‘We won’t pay for this’? [But] those who pay for care have to understand how to make decisions and build the infrastructure as well.”
By building the infrastructure, such technology can be used to its fullest potential, Millenson says, adding, “And because it’s so expensive, that makes it even more important.” He notes that genetic testing is like any other clinical intervention: “It can be wonderful or not as effective as we hoped.”