How Personalized Medicine Can Accelerate the Shift to Value-Based Care

Personalized medicine, therapies that are customized based on patients’ genetic and molecular makeup, is expected to improve outcomes and help direct patients away from therapies that don’t work for particular patients. The promise has been value-based care that is aligned with the Triple Aim: improving the patient experience, improving population health, and reducing costs.

Nicole (Gupta) Bulochnik, Pharm.D.

But thorny issues related to pricing of personalized medicines, reimbursement and patient cost can muddy the value of personalized medicines, Nicole (Gupta) Bulochnik, Pharm.D., vice president, drug pricing and network strategy at Abarca Health, told Formulary Watch.

At the second annual Abarca Forward, a meeting sponsored by the PBM and held Feb. 15-17, 2023, in Puerto Rico, Bulochnik considered how personalized medicine could accelerate the shift to value-based care.

“When I think of the promise of personalized medicine, I think of tailored, customized, and — this is not something you generally say about personalized medicine — cost savings and decreasing costs,” she said in an interview. “Where personalized medicine and value-based care align is on improving quality and population health overall.”

Personalized medicines are expected to grow in the future. So far, as of January 2023, 207 drugs are listed with pharmacogenomic information either by the FDA or by the Clinical Pharmacogenetics Implementation Consortium (CPIC), according to a review by Manchester University for the Personalized Medicine Coalition.

Personalized medicine, Bulochnik said, can lead to fewer doctor and hospital visits, shorter duration of hospital stays, and other medical offsets. “Those medical offset are the key to looking at that savings picture and reducing that total cost of care,” Bulochnik said. “And it’s in the long term, maybe five or 10 years, where we notice the benefit and see an ROI.”

The Centers for Medicare and Medicaid Services will drive the shift to personalized medicine if it can fit in that construct of value based care, she said, making coverage decisions and providing transparency. “CMS has wanted enhanced transparency in terms of rebates and encouraged that for several years before mandating it this year. We expect big change these next few years as it is now mandated.”

One study published in 2020 in the Journal of Managed Care + Specialty Pharmacy found that payers would provide for precision medicine testing that improved quality of life and increased life expectancy. The investigators in this study suggested that payers would need evidence of clinical utility and better health outcomes to support coverage and reimbursement.

A recent study published in the JCO Precision Oncology about patients with non-small-cell lung cancer found that patients may be missing out on the benefits of precision medicine because of clinical practice gaps. But cancer has been the focus of much of the personalized medicine space Bulochnik says its much larger than that and can even include things such as sensitivity testing for antibiotics to treat infectious diseases. “It’s really about really tracking treatment regimens and ensuring overall population health,” she said.

Payers in the future, Bulochnik said, will work with their PBMs to track data over time to determine the value of personalized medicine.

Abarca, Bulochnik said, is beginning two pilot projects to determine the short- and long-term ROI for personalized medicine. “We want to quantify the ROI. We are working now to develop the programs, how it will work, the data exchange,” she said.

The first pilot begins in the next few months and Abarca hopes to have some preliminary results by the end of the year. A second program will begin in the second half of the year if the ROI requirements can be met.