As health plans prepare for precision medicine, an effective program takes a comprehensive, systematic approach that includes measuring, defining and managing advanced diagnostics over time and rewarding best-practice use. This should be done in collaboration with their lab partners and includes:
- Measure: Looking at test volumes and costs retrospectively is one means of measuring utilization. Equally important is notification at the point of care, wherein providers and labs have a mechanism to notify the health plan prior to performing a specific test. Doing so helps the plan identify outliers early and provides information to the plan as to what labs have the capabilities to perform which tests, while reducing the burden of requiring authorization for everything.
- Define: 80% of spending on genetic testing is concentrated across roughly 2,500 tests. It makes sense to focus intervention initially on managing the highest-cost tests. Plans should define medical, benefit, network and payment policies for these tests, using the best evidence as it becomes established. Feasibility of preauthorization can then be determined through the measurement step above.
- Manage: The most effective programs will integrate clinical and financial policy in real time within the ordering workflows of physicians and labs. It is now possible to provide real-time, fully automated molecular diagnostics decision support at the point of care, with appropriateness review driven by evidence-based criteria. A fully automated decision support system not only drives those activities that typically are done manually, such as notification and preauthorization, but also guides and incentivizes physicians to work with in-network labs. Intervention needs to be exception based – by managing those instances that require review and simply measuring the rest – the system becomes much more efficient and effective.
- Reward: Medical practices and labs that consistently meet utilization criteria can be made exempt from arduous authorization and approval processes and only need to submit a notification. They can also participate in pay-for-performance programs, risk sharing, alternative quality contracts, or receive other incentives to drive optimal ordering.