Managed Care - January 2009 - (Page 20)

ready included medical tourism in their programs and started to send employees overseas for health care, achieving discounts as high as 90 percent on major surgeries. PERSONALIZED MEDICINE In personalized medicine, patients are classified into subpopulations according to their susceptibility to particular diseases or their responses to certain drugs or treatments. This allows use of the most appropriate therapies for individual patients as well as populations. Though the definition sometimes encompasses such categories as imaging, we focus here only on one facet, pharmacogenomics, the study of how individual genetic differences affect drug response. Typically, a drop of blood, saliva, or tissue used in genetic tests can distinguish patients who will benefit from drugs from those who will suffer adverse effects or have no improvement. The enabling technologies for this disruption are advances in genomics and molecular biology. The $2.7 billion sequencing of the human genome in 2003 accelerated the development of tests significantly. Its business model allows public and private companies to sell the tests commercially through laboratories to physicians for carrier payment, as well as some direct-to-consumer marketing. It disrupts the status quo because the gene tests help to create specialized drugs targeted perfectly to affect small populations, instead of the Big Pharma model of blockbuster drug releases. About 50 percent of all people do not respond to the drugs they take, says Joanne Armstrong, MD, senior medical director for women’s health and clinical leader for genomics at Aetna. This leads doctors, who often rely on intuition, to engage in expensive trial and error, trying patients on different medications until they find one that works — what Christiansen et al consider a lack of precision in medicine. Genetic tests deliver predictably effective therapy, such as Genentech’s test for receptivity to the infusion medication Herceptin in patients with HER2positive metastatic breast cancer. “The tests allow you to diagnose so precisely, it takes the guesswork out of health care delivery,” says Hwang, the internist and co-founder of the Innosight Institute. Moreover, pharmacogenomics results in meaningful cost savings to the health care system, according to the September 2008 report of the President’s Council of Advisors on Science and Technology, “Priorities for Personalized Medicine.” Using genetic information to determine warfarin dosing alone could save $1.1 billion annually, according to a 2006 working paper of the Brookings Joint Center for Regulatory Studies. “Drugs that don’t work perfectly well [for everyone] but work for many people are big pharma’s best drugs, and that’s exactly what a blockbuster is,” Hwang notes. “Safer drugs that treat disease perfectly for a smaller percentage of patients will disrupt this market.” Armstrong predicts genetic testing will soon become the standard of care for certain medications. Medco Health Solutions, the pharmacy benefit manager, is betting the farm that genetic testing will be the next big thing. Medco started researching patients’ chemical reactions to different drugs in 2003. In October, Fortune Magazine named Medco the third most admired worldwide company, after Apple and Nike, in part for its effort to mine genetic information to determine how patients metabolize drugs. “Genetic research will rapidly move toward a standard practice in administering drugs within the next two to five years,” predicts Medco CEO David B. Snow Jr. Many barriers to acceptance remain. For payers, there is a fear of false positives and false negatives, fear of physicians over-ordering tests, and lack of evidence supporting safety and efficacy, Aetna’s Armstrong says. Though Aetna covers hundreds of the more than 1,000 tests, “They have varying levels of efficacy and from a health plan point of view, varying levels of coverage.” In addition, many doctors lack training to order and interpret tests, according to a May 2008 study by the health and human services secretary’s Advisory Committee on Genetics, Health, and Society. Some developments may change the horizon for acceptance. In August 2008, the FDA allowed the manufacturers of the blood thinner Coumadin (warfarin) to change their labeling and advise physicians that genetic testing may help with dosing and reduce complications. The tests will grow in number for general practice if they are built into IT-based clinical decision support systems embedded in electronic medical 20 MANAGED CARE / JANUARY 2009

Table of Contents Feed for the Digital Edition of Managed Care - January 2009

Managed Care - January 2009 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Health Care's Disruptive Innovations Q&A With Clayton Christensen 'Disruption' May Be Plans' Best Bet Avoid the PBM Rebate Trap HealthPartners Puts Diabetes on Notice Formulary Files Plan Watch Tomorrow's Medicine Ad Index Outlook Unmet Needs in the Management of Plaque Psoriasis Impact of RSV: Implications for Managed Care

Managed Care - January 2009

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