A Call to Action

There has been much discussion and debate on the compatibility of personalized medicine and clinical pathways. Many view clinical pathways as identifying the most appropriate treatment options based upon medical evidence, and that the increased utilization of genomic profiling via NGS analysis, or taking into consideration patient preferences, may have a negative impact upon monitoring treatment pattern consistency with clinical pathway programs.

The 2000 JCP Care Pathways Workgroup concluded that, while clinical pathways may indeed outline treatment options based on clinical presentation and medical evidence, the most appropriate treatment options will be determined by consideration of additional clinical presentation specifics (eg, predictive and prognostic profiling, and patient preferences and needs).

In a new podcast series, Oncology Innovations, Gordon Kuntz talks with Bryan Loy, MD, MBA, from Humana, and Tushar Pandey, MBA, CEO of SimBioSys, an early-stage startup that has created a unique approach toward precision medicine. Dr Loy discusses the two sides of a health plan; the operational side where coverage policies are developed based upon information provided by medical evidence and personalized testing, and the development side for coverage policies for those new technologies that drive the operational decisions, such as testing, biomarkers, and next-generation sequencing molecular panels.

From the new technology perspective, SimBioSys developed TumorScope, a software application that creates a virtual 3D model of a patient’s tumor space from standard of care imaging, and then empowers the clinician to test the treatment options that are indicated for that patient prior to initiation of treatment.

In another interview, Ann Nguyen, PharmD, Vice President of the Enterprise Pharmacy at OptumCare, a division of the UnitedHealthcare Group, discusses her efforts to implement clinical pathways into the OptumCare family of medical practices while addressing the financial risks of this venture, and the main goals and focuses of this clinical pathways program.

Our first feature article this month is phase II of the Specialty Care Medical Home model. Lili Brillstein and her team describe how a no-risk model is a thoughtful and important step that allows providers to participate and study the claims and data and identify the most effective and thoughtful use of resources, as well as identify appropriate prospective partners.

Our second feature article describes the ability of biosimilars to have a significant impact on the oncology cost of care. From a medication utilization perspective, oncology medications are among the top three drivers of cost trends. Biosimilars have the potential to blunt the cost curve; however, utilization remains low for oncology indications compared to reference products, especially compared to the utilization levels by our European counterparts. There are various reasons for the slow uptake, and they usually point back to an effective mechanism of steerage not being in place. This piece describes a program put into place by eviCore to drive biosimilar utilization for three common biologic drugs used for cancer treatment (trastuzumab, rituximab, and bevacizumab), and the resultant financial savings generated.

Don’t forget to take a look at some of our online exclusive content, catch up on recent news, and see what’s trending from the ACCC.

I hope you enjoy this issue. As always, feel free to email us with any comments, questions, or suggestions. Additionally, if you’d like to submit your data, please go to our website.