Precision medicine is still in its early stages, but it already has the power to disrupt your practice. Here are five considerations for when and how to add genomics and precision medicine
When healthcare leaders talk about the financial implications of care models like precision medicine, their thoughts often focus on the return on investment (ROI). How much will it cost to take this case to the precision medicine level? What are the potential downsides? What could it add to our bottom line?
Physicians who get on board with precision medicine early should note: It’s often difficult to prove the ROI of new modalities immediately. Early adopters must consider the broader financial implications and factor qualitative value into the overall equation, especially as precision medicine evolves. Most physicians recognize the inherent benefits of diagnosing and treating patients more precisely, but it will take time to generate the necessary body of data to demonstrate the positive return for adding precision medicine to the mix.
Below are five factors practice leaders must explore to evaluate how quickly to bring genomics and precision medicine into their daily practice.
Today, most physicians practice trial-and-error medicine. They evaluate symptoms, arrive at a diagnosis and proceed with the most likely or common treatment.
A prime example occurs in patients diagnosed with anxiety or depression. How often do we select an antidepressant, try it for a few weeks with little effect, increase the dose for another few weeks and - if that fails to produce the desired outcome - start the process all over again? Relief for the patient could take months, during which time resources are being consumed in the form of prescription costs, office visits and wasted time.
But a pharmacogenomics test can cost as little as $200, and the results can be made available within the clinical workflow. Those results could equip physicians with the information to select the best medication for the individual patient, the first time around.
Determining the best treatment for patients is tricky, but insight into genomic markers enables physicians to know when a novel therapy might be the best choice. Consider evolocumab (Repatha). It is costly but highly effective for patients with familial hypercholesteremia (FH), a genetic condition that drives up LDL cholesterol levels regardless of lifestyle. If patients undergo genomic testing to identify whether they carry this variant, practices could stratify their population to determine risk. Physicians could then appropriately prescribe evolocumab without wasting time on other treatments or prior authorization because they have scientific proof the drug is appropriate.
The formula for value-based success aligns with the objectives of precision medicine: treating patients effectively, more quickly and without unnecessary cost. Genomic testing arms physicians with an unprecedented level of insight into a patient’s condition so they can determine the best individualized care plan - and sooner.
Let us look at the patient with high LDL. Without genomic testing revealing the genetic variant for FH, physicians would follow a standard course of treatment: prescribing a statin. When the first medication does not work, physicians would work their way down the list of typical drugs. Costs mount, outcomes remain poor and the practice fails to meet quality measures for treatment of high cholesterol. A simple genomic test, on the other hand, allows physicians to easily diagnose FH and deliver successful care sooner.
Precision medicine and genomics are complex disciplines, and front-line physicians may understandably struggle with the learning curve. Which patients should we refer for genomic testing or counseling? And, of the vast array of genomic tests (carrying vastly different price tags) available through a plethora of molecular labs, which are the best tests to order for the patient sitting in the exam room?
Education and training are, of course, important components to helping physicians become comfortable with these new and exciting approaches to care. It is equally vital that practices seek point-of-care tools that guide physicians. Key considerations include the ability to gather highly detailed family history (beyond the limited aspects offered by EHRs) to help them identify possible heritable risk in individual patients. In addition, practices need to make genomic insights easily available within the workflow, integrated with the clinical record and presented in a way that is meaningful to physicians.
Last, but not least, practices must consider consumer demand. The general population is acutely aware of the potential of genomic information. Many patients are already trying direct-to-consumer (DTC) tests and challenging their physicians to incorporate those results into care plans. Practices must respond quickly to retain patients and remain competitive.
Practice leaders must likewise figure out how to handle the downstream effects of genomic demand: Patients might request additional tests, both necessary and unnecessary, based on their self-sought test results. In today’s changing times, it would be wise for practices to implement new policies and procedures to handle DTC tests and address the consumer movement.
Many variables must be considered as we explore the financial implications of precision medicine and genomics. The ROI picture is not clear yet, although all indications point toward positive impacts on quality of care, patient satisfaction and the bottom line.
Joel Diamond, MD, FAAFP, 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 practices at Handelsman Family Practice in Pittsburgh. He serves as Chief Medical Officer for 2bPrecise, a business segment of Allscripts, which uses data models, complex ontologies and clinical integration to enable providers to leverage the value of genomic data at the point of care.