For personalized therapies to be incorporated into a plan's coverage, a commercially insured enrollee would need to stay with the plan for many years, as more expensive therapies require longer member retention to break even, according to Deloitte.
For personalized therapies to be incorporated into a plan’s coverage, a commercially insured enrollee would need to stay with the plan for many years-more expensive therapies require longer member retention to break even-according to a new report by the Deloitte Center for Health Solutions.
“In the case of Herceptin, for instance, its use reduces the need for chemotherapy for certain women: in a scenario where a personalized therapy points to an additional therapy added to the standard course of treatment, plans are also at a disadvantage due to the incremental costs for the combination therapy,” says Paul Keckley, PhD, executive director, Deloitte Center for Health Solutions.
By contrast, a diagnostic test that’s precise in predicting a condition leading to a more precise diagnosis and effective treatment plan provides a positive ROI to plans.
According to Keckley, for managed care executives, the challenges are: (1) to monitor the relative efficacy advantages of personalized therapies as they become available to the market as well as companion diagnostics; (2) to communicate relative advantages and risks to members so informed decisions are made in a shared decision model; and (3) rationalize appropriate use of personalized therapies in coverage and premium planning.
Three trends converge as key context for the study, “Achieving ROI in Personalized Medicine: Barriers, Incentives and Pathways to Successful Commercialization.” They are:
• Increased interest in biologics (genetically/molecularly based medicines) prompting many consumers, physicians and plans to substitute traditional drugs for personalized therapies where cost effective;
• Increased pressure on health plans from consumers and providers to be transparent in coverage and denial decisions; and
• Pressure on health plan operating margins as employers and the government attempt to reduce health costs.
“These three pose a challenge to manufacturers of personalized therapies who wish to be covered by plans as a first line of treatment where their relative efficacy is superior to standard care,” Keckley says. “In many plans, personalized therapies end up in tier four of the plan’s formulary-available only to a certain subset of members for whom additional costs can be justified.
As plans transition product offerings to a retail market model-consumers who own individual policies-plans must take the lead in providing useful information to members so they make appropriate judgments about the medications and tests recommended for their unique circumstances, according to Keckley.
TriZetto CEO Jeff Margolis believes that with an increase in healthcare consumerism comes a transformation to whole-person healthcare or, as he calls it, integrated healthcare management (IHM).
“The vision of IHM is to have the payer systemically optimize benefits and coordinate care for the member,” Margolis says. “Each member has different health needs, so tailoring a benefit plan to a consumer’s specific health status, life stage, and personal value system encourages members to follow evidence-based medicine guidelines, lowers costs and puts them into an informed decision-making partnership with the provider. While today, this coordination is likely manifested primarily in wellness programs and DM, personalized medicine will likely also fall into this vision in the future.”The opportunity for plans is as “info-mediary.” Consumers trust plans to provide valid and useful comparisons of treatment options, Keckley says.
“They consider plans honest brokers of information. They want help in making decisions about their treatment options and associated costs at the time a service is needed,” he says. “The most significant role plans should play is to provide actionable information to members so they make appropriate decisions.”
Mark Selna, MD, senior vice president of clinical advocacy at BlueCross BlueShield of Tennessee, says that since every one of its members has different needs, preferences, motivations and benefit plans, BCBSTN is continually investing in the use and development of customer relationship tools.
“These tools assist us in understanding the member’s needs, as well as, helping members to identify their gaps in care, develop lifetime health improvement plans, maximize the use of their healthcare benefit and make meaningful connections with like-minded peers,” Dr. Selna says.