Personalized Medicine: A Payer’s Perspective

To celebrate the highly anticipated 12th Annual Personalized Medicine Conference, Slone Partners offers a special PMC interview series featuring four key thought leaders. In the past few weeks, Slone Partners has shared with you insightful interviews with Dr. Stephen Eck, VP of Oncology Medical Sciences at Astellas Pharma Global Development, Dr. Amy Abernethy, CMO, CSO & SVP of Oncology at Flatiron Health & Dr. Michael Pellini, CEO at Foundation Medicine.

To conclude this exclusive Personalized Medicine Conference series, Dr. Kristine Bordenave, Lead Medical Director at Humana shares her unique insights on the advancement of Personalized Medicine, the main roadblocks, and areas of regulatory & reimbursement opportunities.

Slone Partners: What are the implications of integrating population health and personalized medicine?

Dr. Bordenave: There are large outcome gaps in population health that could be improved through integration of personalized medicine concepts as the field matures through well-constructed traditional and innovative studies. Culmination of the concepts in population health (e.g. social determinants) and independent variables (e.g. distinct personalities) with advances in technology and a growing comprehension in cellular biology allows for the continued medical evolution supporting healthier populations. The science supporting the development of personalized medicine may soon provide better recommendations to address health and healthcare including understanding the polygenic influences on personality traits, but there is a lot of work needed to ensure that the other social determinants are addressed to support environmental interactions and impacts on health. Robust multifactorial clinical studies utilizing the advances made in proteomics, metabolomics, genomics, complex disease associated cell state assays, monitoring devices and bioinformatics, could define best practices in the not too distant future. In addition the identification of the impact of complex cellular responses in individual’s physical and psychological responses could result in unrecognized interactions between health, education, socioeconomic factors and circumstances of individuals and communities.

Slone Partners: From a reimbursement perspective, how has the ICD-10 implementation been beneficial?

Dr. Bordenave: ICD-10 when used appropriately allows for greater specificity in tailored data analytics utilized to identify missed opportunity such as new services/therapies which prevent disease instability or progression. The difficulty lies in ensuring that the correct code is billed as longstanding practices can be challenging to change.

Slone Partners: What are the key issues with personalized medicine from a payer’s perspective?

Dr. Bordenave: The adoption and routine arbitrary utilization of services or therapies which lack clinical evidence supported by outcome data/studies.

Slone Partners: If you had to pick one, what is the first aspect of personalized medicine that you would change/promote in order to bring down costs?

Dr. Bordenave: We need to support of collaborative multifactorial studies to identify the best constellation of testing for rapid identification of individuals at risk for disease and for those with lack of response to current clinical protocols. Newly identified testing needs to provide outcome data in order to drive changes in existing standards. Consideration of cellular and personality trait responsiveness in varying circumstances and settings would bring new value to the space. In other words, support for robust studies could redefine existing standards of practice resulting in improved clinical outcomes. We need more information about who to treat, when to treat them, and how to treat them to improve outcomes relative to existing strategies.

Slone Partners: Are bundled payment contracts on the rise? If so, will this trend continue?

Dr. Bordenave: Payers utilize a constellation of contract types tailored around member needs, communities and provider/payer business models. While bundling is one type of contracting and may be considered to meet a particular need, the industry seems to be shifting more often to innovative contracting models to better support rapidly changing medical business models.

About Kristine Bordenave

Kristine Bordenave, M.D., F.A.C.P., is the Lead Medical Director for Humana Inc.’s Claim’s Cost Management Division with a special focus on personalized medicine, laboratory services, Medicare regulation, tailored healthcare redesign, and the integration of institutional experience to ensure efficient high quality resources for present and future generations. She has over 20 years of clinical and research experience and is a member of several organizations including: American College of Physicians, AMA, and The National Health Care Anti-fraud Association. Dr. Bordenave has multiple publications and presentations related to chronic disease, systems redesign and population genetics.

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