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Precision Medicine is a ‘Whole New Ballgame for Insurers’

“With precision medicine, we may be able to get a better understanding at what’s most cost-effective."

By Vera Gruessner

- Recently, President Barack Obama has announced a national “Moonshot” program to put an end to cancer as a whole. Vice President Joe Biden has been appointed the main leader of this project, a White House news release stated. A total of $1 billion is being dedicated to begin this effort to eliminate cancer around the nation. Precision medicine could be a key area in which the “Moonshot” program will focus on, as President Obama initially launched a precision medicine initiative in early 2015.

Targeted Drug Therapy

While the “Moonshot” program to end cancer will target the development of cancer vaccines and effective immunotherapies, precision medicine will be used to tailor treatments for specific subgroups of people by gaining a better understanding of their genetics, environment, and lifestyle, The White House reported.

To better understand precision medicine and how it affects healthcare costs among payers, providers, and the patient community, spoke with Dr. Laurence Altshuler, author of Doctor, Say What?. How does Precision Medicine improve patient care and healthcare delivery?

Dr. Laurence Altshuler: “Most people think of precision medicine as individualized care. In other words, it means really analyzing the genetics of an individual and looking for certain characteristics of that individual to find a treatment. In actuality, it’s not specific people – it’s actually subgroups of people that they’re looking for with precision medicine.”

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“To analyze each individual separately would be an amazing task. An example is a type of lung cancer – adenocarcinoma – in which 10 percent of people would have a mutation called the EGFR mutation. You can treat those people with specific, targeted drugs whereas the drugs won’t work on 90 percent of patients with adenocarcinoma.”

“The second thing you need to know about precision medicine is that it’s not just the genetics of the individuals. It’s also what’s called epigenetics, which means how the lifestyle and the environment of an individual impacts health.”

“If you have a gene mutation that may lead to something, it doesn’t mean it will definitely do that action. It’s influenced by outside forces. When you look at precision medicine, you have to take all of that into account. As a result, it’s a huge field. It’s going to take a lot of work. It’s going to take a lot of research. Computers are going to be extremely important in that.”

“We have 2,000 medical conditions for which genetic testing is available, but it’s only in its infancy and we know very little about it. There’s going to be lots of concerns about it. It’s going to take a lot of work by a lot of people and plenty of collaboration.” What guidelines or strategies would you suggest to providers and insurers looking to improve the quality of care and lower costs among cancer patients?

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Dr. Laurence Altshuler: “Number one, we know that there’s a problem with cost in cancer. Cancer is an extremely expensive disease. A lot of the cost is because there needs to be a lot of testing and scans and repeat testing to see how those cancers respond to treatment.”

“However, the chemotherapies are really priced high. There’s some chemotherapies that are $110,000 or $120,000 for a course of treatment. Sloan Kettering had already refused to use one drug because it was priced way too high.”

“Some of those drugs may only work in a fraction of people or may only prolong survival for one or two months. So why pay that kind of money for that kind of survival? Basically, what we’re trying to look at in cancer is to look at the value of cancer treatment.”

“In other words, for the cost we’re paying, how much quality care do we get? How much response and how much survival do we get for that? That’s where the quality is. Right now, there are no guidelines for that. The guidelines we use for cancer is called the MCCN guidelines and that’s an international group of cancer centers that have written guidelines. Insurers follow those guidelines.”

“Within it, they mention chemotherapy as an indication but there may be different combinations of chemotherapy and different drugs to use, so there are several options within the guideline. What we want to do is to look at the different options and determine what the most cost-effective chemotherapy is going to be. The same thing can be said for radiation therapy.”

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“Different costs and different side effects can be considered. When we’re looking at quality of care, we want the most cost-effective treatment with the lowest side effect. Basically, there’s lots of options available but the guidelines don’t tell you which ones are the most cost-effective and which ones have the least side effects. That’s really up to the oncologist to decide.”

“With precision medicine, we may be able to get a better understanding at what’s most cost-effective. We’re going to need to do a lot more research on those subgroups of people and find which treatments per individual are going to be more effective, will cost less, and will bring higher quality and longer survival.” Are health payers looking to align with providers who offer personalized care? Does personalized care go hand-in-hand with value-based payments?

Dr. Laurence Altshuler: “That’s going to have to be determined in the future. Right now, personalized care will change the whole industry. It’s going to change the way medicine is practiced, how it’s taught, and how healthcare will be provided for every person.”

“Hypothetically, it can be very, very costly when looking at genetic testing and epigenetic and environmental influences. Doing these different treatments may or may not work and may have different effects on different people. It’s a whole new ballgame for insurers.”

“It could be very expensive. It could involve lots of testing and the treatments being developed will be targeted treatments. Among some people, the basic treatments will work. Precision medicine will try to develop target treatments and those are the ones that are most expensive.”

“To develop them, the research is costly and the pharmaceutical companies spends a lot of money on creating these treatments. There are going to be very few targeted therapies for each disease and will be priced high. The insurers will have to deal with this and, hopefully, could make arrangements with pharmaceutical companies to lower the cost.”

“First, they need to decide whether the targeted therapies are effective. If it is, then what is the appropriate cost? And then, is that something that is advantageous for insurers to cover? There are going to be lots of decisions among payers on covering these targeted therapies.”

“Part of the problem is that, in cancer, for example, there are genetic tests that show mutations and that a targeted chemotherapy drug can help with that. However, we’re finding out that the mutation that we think is driving the cancer may not be the active driver. It may be a passenger. It may just be there and not do anything. So we’re seeing some successes but we’re also seeing a lot of failures.”

“All of that will have to be worked out because insurers are not going to want to pay for targeted therapies that don’t work in a lot of people. They’re doing that right now. There’s genetic tests that can show mutations, but if it’s not proven absolutely in research that the drug will help with the mutation, insurers don’t have to pay for it and they’re not paying for it.”

“Also, precision medicine is not going to focus on cancer. They’re looking to focus on Alzheimer’s disease, obesity, heart disease, diabetes, and mental illnesses. Those are even more different because the environmental and lifestyle factors are even more tremendous in those than it is in cancer. This will lead to expensive research and expensive targeted drugs. The whole thing is going to involve so much more than we have right now in our system.”

“It’s going to be tough. Different medical providers, insurers, Medicare, and Medicaid will be figuring out how to fit it all together and give patients the best quality care at the lowest price.” What are some areas in which healthcare spending is increased when it comes to tailored treatments?

Dr. Laurence Altshuler: “The tailored treatments are fairly unique. For every mutation we’re seeing, there may be just one drug or two drugs that can treat it and those are priced higher because of a lack of competition. That’s a big cost. The second cost is in evaluating the patient and evaluating all the factors that are going on. That’s expensive too. There are laboratory costs and testing costs.”

“All of that takes a lot more time as well – the time to really look at every individual and every subgroup and treat them separately or uniquely takes a lot more time. Time is money.”


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