Outdated Metrics in the Age of Precision

Kavita Patel, MD

With the rapid pace of change in precision medicine, insurance companies and federal policymakers are going to have to adjust for far more variance in the ways patients are treated, even though insurance plans and federal policy by nature require a measure of standardization, an expert panel said last month at the 4th Annual Patient-Centered Oncology Care conference, sponsored by the American Journal of Managed Care.

The panelists were not fully convinced that payment and federal policies can make the evolutionary leap with the gracefulness of a ballerina, given that government measurement tools are outdated in many cases, and many elements and entities in oncologic care lack true coordination and transparency.

“The challenge for us is how to deal with this infrastructure that’s very outdated as we’re using it today, yet we need to build the moonshot vehicle with these technologies, with these policies; and that’s where I see a lot of room for creativity,” said Kavita Patel, MD, a primary care internist at Johns Hopkins Medicine and a former director of policy for the Obama administration.

The session entitled “Navigating the Conflict of Personalized Medicine vs. Population Management” covered a wealth of unresolved issues that pose challenges today for physicians, policymakers, and payers as medical science races forward and creates a knowledge vacuum that requires all parties to act with greater nimbleness while shedding institutionalized methodology that impairs the effective delivery of personalized care.

“When we think about personalized medicine, we become so fixated on molecular diagnostic studies that we forget that we’re thinking about a person, and to the extent that we connect all of this technology and honor the humanity of the person, the closer we get to doing the right thing,” said Joseph Alvarnas, MD, director of value-based analytics at City of Hope National Medical Center in Duarte, California.

Finding the right marriage between delivering on value and paying the correct amount of attention to technology is still in the realm of a Holy Grail quest, he said. “For us, it’s finding the right valuation tools to glean for our patients whether we’re adequately serving their needs, and that’s tough. I haven’t seen a perfect tool yet.”

Population health and precision medicine couldn’t be more at odds with each other than cats and dogs, said Burton F. VanderLaan, MD, medical director at Priority Health, a nonprofit insurer in western Michigan.

Population health looks at the whole cost of care, with a focus on chronic conditions and social determinants of health. The desire is to standardize treatment and to reduce variation through the use of guidelines, partly through coverage policy, VanderLaan said.

On the other hand, precision medicine in oncology puts the emphasis on allowing for broader variations in care because of the focus on highly individualized therapy, he said. There is no general goal to improve the health of the overall population.

“This is the interesting paradigm that the health clinics are operating under,” VanderLaan said. Payers, he said, are going to be challenged to “reinvestigate the evidentiary basis that they use to determine coverage policy.” Science is outpacing the slow and steady progress of clinical trials, to the point that “we just don’t have the luxury of waiting for them in order to craft appropriate coverage policy,” he said.

Measuring the Quality of Care

He said that the solution being imposed upon payers is that they base their coverage decisions on varying levels of evidence, among them adaptive trials, phase II trials, and basket trials. “Plans will have to become a lot more comfortable with the notion of variation, because when you’re individualizing therapy, that’s going to become a given,” he said.The tools needed for measuring the effectiveness of care in this new environment just don’t measure up, said Alvarnas. He said that part of his job at City of Hope is “creating a language that’s transparent enough to transcend the limitations of ICD-9 and ICD-10, so that you can spot good care when you see it and mismatches when they occur.”

In an ideal world, a shift to value based payments would be much more patient-centered that what exists right now, said Patel. “I don’t think patients care so much if it’s a fee-for-service setting, or a capitated setting, or an episodic/bundled setting. They just want to see those outcomes that they desire.” Part of the problem is that physicians have to think in terms of population management, whereas patients may simply want more time in the examination room with their doctors. “That can create a tension,” Patel said.

When the discussion shifted to financial health literacy, Patel argued that there isn’t enough transparency in health costs to guide patient financial decisions. “When I worked in the administration, I wanted to inject more of a forced conversation about copayments, deductibles, premiums, and out-of-pocket costs,” she said. “The rules and regulations tried to cover those issues. I don’t think they have. Most physicians that I work with are not equipped to talk about the financing of health care with most patients, and most patients when they come to access the health system for the first time are actually kind of shocked by how little they know about their own payments and deductibles." She cited an example of how “coverage” under a plan may actually mean an 80% out-of-pocket cost for a particular drug. “In the United States, it matters where you get care, and you can’t even use experiences from one market to another to make assumptions,” she said.

There’s truth in that, but you may end up shortchanging the patient if you try to commoditize healthcare down the penny the way other products and services are sold in the United States, Alvarnas said. “I would argue that then we lose the integrity of healthcare—delivery that allows us to take a very sick patient and hopefully have one who’s restored to health at the end of it,” he said.

VanderLaan said an “unstructured and siloed” healthcare system is partly to blame for the existence of information bulkheads that allow information to flow freely in some sectors and poorly in others. “In different communities there are very different levels of integration.” Resolving this problem is a long way off, he said.