How lucky we are to be alive right now.” Those lyrics from Hamilton, when applied to innovation in health care, remind us how often life imitates art. One of health care’s most dramatic advances has been the progress of precision medicine, wherein medical treatment is tailored to the individual characteristics of each patient. Yet payers and providers have been slow to adopt precision medicine.
Health plans can change that by extending coverage and ensuring that genetic testing and therapies provide value. However, this opportunity raises questions for health plan leaders on where to invest—and how to access the best data needed to inform decisions.
Payers interested in taking the lead in precision medicine should consider these three critical actions.
Tie precision medicine to innovative value-based payment contracts. Exciting developments are taking shape around health plans’ approach to precision medicine risk. For example, Harvard Pilgrim Health Care signed a value-based contract with Illumina, a genetic technologies company, centered on next-generation sequencing. Harvard Pilgrim has agreed to cover the cost of noninvasive prenatal genetic testing for younger women, even those with average-risk pregnancies. As a result, the insurer is playing an important role in expanding testing for a broader population.
The Harvard Pilgrim example shows a shift from the traditional approach to value-based payment that is based on standardization of care. But that established formulation may not align with precision medicine, where testing and treatment is based on factors such as the individual’s family history and genetic profile.
Health plans can develop a value-based approach to precision medicine through shared-risk arrangements, such as monthly payments for members’ access to specific tests, not to exceed a predetermined amount.
One place to begin: Coverage for treatments with proven clinical efficacy or genetic tests that are backed by significant data, such as genetic testing for cancer.
Invest in infrastructure for precision medicine data collection, sharing, and storage. At a time when more than 75,000 genetic tests are on the market and numerous new tests are introduced each day, three out of four providers say existing electronic health record functionality is not adequate for advanced precision medicine and clinical decision making support. Meanwhile, data-storage capabilities aren’t keeping up with the continually increasing amount of member data.
Health plans should outline the data and data sources needed for effective decision making. Then they should partner with organizations to implement platforms that enhance data permutations and accessibility. Tools that link financial and clinical data can help health plans better assess the value of specific tests and therapies based on clinical effectiveness and cost.
Adopt artificial intelligence and rapid-learning systems that extract more meaningful information from clinical and claims data. AI shows high potential to transform massive amounts of genetic data into clinically actionable knowledge, such as the ability to target the right treatments for specific cancers. Data insight platforms that make sense of clinical, cost, and genomic data are critical for:
Some health plans are investing in predictive analytics to assess genetic claim trends. They are using the results to zero in on top areas of genetic testing spend. Certain patterns can point to overbilling, such as billing for multiple units of service and inappropriate coding.
Health plans can lead wide-scale precision medicine adoption, but they need access to data-informed insights to make the right coverage decisions and support clinically effective care. As precision medicine continues to revolutionize health care, a value-based approach will deliver better outcomes for all stake-holders.