The Benefits and Challenges of Precision Medicine for Health Plans

Bill Kerr, M.D., MBA

Powered by genetic and biomarker testing, precision medicine tailors healthcare to individual patients based on their unique genetic, lifestyle and environmental factors. It can guide targeted cancer treatments, gene-based therapies, predictive disease testing, therapeutic drug monitoring and more. Its potential to save lives and produce better outcomes is truly amazing.

However, as is the case with many medical advances and innovations, the use of precision medicine, although growing fast, remains uneven and inconsistent. That is a problem for everyone in healthcare, but particularly for patients who would benefit from it but who, for whatever reason, never get the opportunity.

Underuse of testing

Even as precision medicine advances, the challenge of implementing it remains. The use of genomic testing and targeted therapies to advance treatment has been most advanced in oncology, but widespread adoption has been elusive.

For example, precision medicine has been shown to improve diagnosis and outcomes for patients with non-small cell lung cancer (NSCLC). However, enormous gaps in care remain. Many patients either go untested, miss out on appropriate therapies, or experience unnecessary delays between diagnosis and treatment. These disconnects undermine the integration of testing and therapy, limiting their ability to deliver optimal results.

Consider the following statistics:

• A retrospective study showed that only 18% of NSCLC patients received all gene mutation tests recommended by the National Comprehensive Cancer Network (NCCN)
• 43% of members with NSCLC are on a biomarker drug, with no evidence of them undergoing a genetic test to show that the drug is appropriate for their cancer
• In a study of over 27,000 members with NSCLC, 29% were not on the appropriate targeted treatment based on their lab results
• In a study of over 9,500 members with NSCLC, 44% had a positive biomarker and were not on the NCCN-recommended therapy.

And that’s just one form of cancer. Personalized treatment of other cancers and diseases has similar disconnects. We have a long way to go to make personalized medicine a fully integrated part of healthcare. The need is there; the tests exist. Now, it’s a matter of purpose and alignment.

How health plans can advance personalized medicine 

Health insurance is often the deciding factor in whether someone benefits from precision medicine. Although health plans are excited about personalized medicine’s ability to deliver more effective care and better outcomes, coverage policies can be inconsistent and often trail advances in the field.

Realizing the maximum benefit from precision medicine will require collaboration between providers and health plans to ensure that the right people receive the right tests and that the results lead to the correct therapies. This is made more difficult by the highly personalized nature of precision medicine. Blanket coverage policies don’t work because the efficacy of a treatment can vary from person to person.

Genetic and biomarker testing require more management from health plans than routine testing does. The volume of these tests is exploding and overwhelming the plans’ ability to evaluate their validity and utility. As a result, plans’ coverage criteria can quickly become outdated.

It’s critical that coverage criteria be rooted in the latest science, as regularly reviewed and updated by experienced working laboratorians, pathologists and geneticists. The increase in the number of tests is also exposing the inadequacy of the current coding system under which laboratories perform the same or similar genetic tests while billing with different combinations of CPT codes.

While coding tools like MolDX and Concert Genetics are helpful, they must be integrated into comprehensive programs to be effective. Establishing coding requirements for each test at each laboratory allows streamlined operations and more comparative analytics within the plan. The test specificity concepts discussed provide a clean, robust and efficient means to overcome potential code challenges and clarify provider billing requirements. Health plans adopting a specific method for test identification will see increased efficiency, improved laboratory and physician satisfaction, and reduced potential for fraudulent billing.

The road ahead

The genetic and biomarker testing that powers precision medicine also requires adjustments from plans. Precision medicine could complicate efforts to expedite or eliminate prior authorizations (PA). More states are passing legislation to eliminate PA or shorten waiting periods. Other legislation creates “gold card” programs that eliminate or reduce PA requirements for providers who meet benchmarks for having had PA requests approved.

However, this contradicts the fact that precision medicine requires precision reimbursement policies. “One size fits all” coverage decisions will not be as applicable because plans will have to consider whether a treatment is effective for a specific patient, based on testing and experience. PA, while despised by providers, could become more essential to prevent coverage of treatments unlikely to work for an individual patient.  

Personalized medicine is well on its way to becoming not only accepted but also expected by patients. While this presents many challenges for health plans, such as coverage gaps, inconsistent policies, and differing approaches to what is experimental and what is proven, these can be addressed through a dual commitment to basing policy on science and prioritizing what is best for patients.

Bill Kerr, M.D., is CEO of Avalon Healthcare Solutions.