With all this talk of moonshot missions and initiatives, it’s not surprising that the healthcare industry often overlooks one of the greatest barriers to implementing precision medicine.
During a Thursday panel at the MedCity INVEST conference in Chicago, Manoja Lecamwasam of California-based Dignity Health reminded the audience what it’s all about.
As a non-profit hospital and care facility network, Dignity Health is preparing for a future centered around precision medicine, Lecamwasam explained. Early resources have been committed towards training physicians and implementing tools that can deliver actionable data at the point-of-care.
That’s important, she said, because some 80 percent of cancer care has historically been managed through community hospitals. Dignity’s aim is for those patients to have the same access to personalized medicine as those treated at the major centers.
Fellow panelist Paul Billings of the Bethesda Group respectfully disagreed.
“What you’re talking about, in my view, isn’t precision medicine. It’s equitable medicine,” Billing told Lecamwasam. “Precision medicine is that you do the right thing, to the right person, at the right time.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Five minutes in, it felt like the panelists were debating two different concepts. The vagueness of the term “precision medicine” (or “personalized” for that matter) suddenly hit home. But as the session continued, it became apparent that they were on the same page, just looking at the text from opposing angles.
Layers of precision
For many industry observers, precision medicine is what’s happening at the forefront of scientific advances and milestones, often announced by major hospital centers such as Mayo Clinic, Cleveland Clinic, and Memorial Sloan Kettering. The discussion centers around issues such as the number of companion diagnostics in the pipeline, development incentives, and how machine learning can help doctors select the optimal cancer treatment based on DNA, or RNA, or digitized pathology slides.
In practice, precision medicine relies on many more mundane things, which is what Lecamwasam sees first hand.
To do the right thing, doctors need to make treatment decisions that aren’t bound by insurance coverage or out-of-pocket costs. A solution to this dilemma is not coming anytime soon, so how about another example?
To treat the right patient with the right therapeutic, physicians need to be up-to-speed with all the latest research and guidance.
Likewise, treating the right patient at the right time, often require access to clinical trials. How do we ensure broad recruitment throughout the United States?
Lecamwasam spoke in even more basic terms. Can they afford the bus ticket to get to the clinical trial site?
For precision medicine to do the right thing, to the right person, at the right time, that person’s life – not just their genome – needs to be taken into account.
In fact, some studies have suggested that up to 80 percent of the factors that influence a person’s health are due to socioeconomic, environmental, or behavioral factors – not healthcare quality or access. To make an impact, companies like Dignity Health have to adapt precision medicine to address the needs of diverse communities throughout the U.S.
From left to right: Nitin Naik, global VP of life sciences at Frost & Sullivan; Manoja Lecamwasam, exec. dir. at Dignity Health; Paul Billings, Partner at Bethesda Group; Franziska Moeckel, assistant VP of personalized health at the Inova Center for Personalized Health
It’s not just a socioeconomic phenomenon. Fellow panelist Franziska Moeckel from the Inova Center for Personalized Health also encounters barriers in her work introducing personalized medicine to state-of-the-art hospitals around the Washington D.C. area.
“We have single gene tests, which are covered. But it’s still very hard to realize that reimbursement,” Moeckel said. The hospitals regularly have to negotiate patients’ coverage on their behalf. Oftentimes, tests will be bundled into existing packages so there’s no option for direct or additional reimbursement.
It’s a steep learning curve for everyone downstream of the fast-paced precision medicine advance that we see on the news. For every test that gets commercialized, healthcare teams around the country have to adapt and train physicians, genetic counselors and more.
“We’re are trying to solve basic problems right now,” Lecamwasam explained. So if the adoption of specific tools for precision medicine sometimes seems slow, she cautioned that it’s not because providers don’t want to try. They just first need to build the practical foundations so the tools can eventually treat many patients at scale.
Why does all of this matter?
One of precision medicine’s greatest limitations continues to be “ignorance,” Billing told the crowd. Genomics opened up a new frontier. Yet our understanding of the many other factors that impact the way a patient responds to an oncology drug, for example, is still in its infancy. Beyond designated biomarkers, what’s happening with the individual’s microbiome, metabolome, and proteome?
“There’s a lot of variability that is determined by basic biology that we will have to integrate into our testing,” Billing said. And testing is just the beginning. It also needs to be interpreted and made available at the point of care.
Who’s to say social, cultural, and environmental factors aren’t as critical?
Precision medicine’s aim is not to optimize the health of one individual. It seeks to systematically shift the entire medical practice and improve outcomes on a population-wide scale. One by one. Whether socioeconomic factors are a part of this new paradigm, or simply a barrier to its implementation, there’s no getting around their existence. Which is why we need organizations like Dignity Health to realize the precision medicine dream — in its entirety.
Photo: PeopleImages, Getty Images
