The Shift Toward Precision Medicine Requires Claims Data Insights

Healthcare today is evolving into precision medicine, or what the FDA refers to as personalized medicine.  To stay competitive in the constantly shifting healthcare landscape, organizations across the healthcare ecosystem must embrace this targeted approach and leverage the tools needed to make safe decisions for their patients or populations. By unlocking insights provided from advanced claims data, precision medicine can assist clinicians, thereby reducing their educated guesses, improving patient outcomes, and making more informed decisions.

Why the hype around precision medicine?

  1. Embracing this approach allows for tailoring the treatments to the genetic makeup of the patient.
  2. Clinicians can use the patient’s genetic makeup and information about the diseases to help ensure the products are both effective and safe.
  3. Precision Medicine reduces unnecessary poor patient outcomes like adverse drug events (ADE) or toxicities.
  4. Patients are empowered through better control over their disease and treatment and can get a more accurate disease diagnosis.

Leading pharmaceutical companies, including AstraZeneca, refer to precision medicine as “a critical approach to drug discovery”, and Genentech “from its inception has been focused on the adoption and utility of biomarker testing, which are some of today’s most urgent barriers to personalized cancer care.” Yet despite the promise in that area, the door to biomarker testing is not open or available to all patients. This could be due to a myriad of factors including but not limited to access.

Before diving into a deeper analysis of patient access, we ask ourselves the following questions:

  • Are there certain groups or communities that have greater access compared to others?
  • What providers are utilizing this personalized approach to treat their patients?
  • Are there certain providers that are more innovative?

By leveraging healthcare claims data with advanced analytics applied to the claims, the end user will be able to determine what communities have access to biomarker testing.

Solving for Access

At PurpleLab®, we created a crosswalk (mapping) that leveraged laboratory testing codes from Quest Diagnostics and LabCorp and mapped them to CPT4 codes. The clinical team at PurpleLab reviewed 100+ biomarkers from the FDA, linking them to the appropriate medications that the biomarkers target based on diagnosis (ICD10CM) and procedure (CPT4). For example, the biomarker MET, which has relevance in non-small cell lung cancer (NSCLC), was mapped to the appropriate codes for the corresponding medication treatment. This unique classification system allows clinicians to make appropriate decisions regarding the treatment for NSCLC.  

Why Work with Precision Medicine?

Precision Medicine allows organizations to:

  • Manage appropriate patient selection for clinical trials and help to identify any ADEs.
  • Identify an individual(s) with a disease/condition.
  • Opportunity for provider education by clinical liaisons/representatives
  • Targeting/Recognizing innovative providers that are using biomarkers versus those providers that are not testing.

Precision Medicine allows Plans to:

  • Access data to support approval of appropriate testing for plan members.
  • Act as a clinical decision support tool for the medical/pharmacy policy teams.
  • Assist with Prior Authorizations (PAs) and case management departments.
  • Track outcomes and projected savings for those who are on the medications that got tested vs those who did not get tested.

Precision Medicine allows organizations to:

  • Biomarker testing can help confirm diagnoses.
  • Ensures patients get the right treatment at the right time to improve health outcomes.
  • Ability to track outcomes and cost for the patients that get tested compared to those that are on specific medication that did not get tested.

Need More Information?

Questions? Ready for a demo or free trial of our HealthNexus™ platform? Contact us to get started.