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Pharmacogenomics: Getting it right the first time

The ROI is in no longer going about treatment by trial and error.

Susan Morse, Managing Editor

The Murfreesboro Medical Clinic and SurgiCenter in Tennessee has gone beyond the cutting edge of using precision medicine in everyday clinical care, according to Dr. Nicholas Cote, CMIO and president of the MMC board.

"We're way ahead of the curve because we're bleeding edge, not just cutting edge," Cote said.

MMC is a large, physician-owned practice that includes more than 90 doctors, a large pediatric practice, internal medicine, medical pain management and other specialities. The practice has worked with its molecular lab partners to get the out-of-pocket cost for a genomic test down to $99, and it encourages all patients to take it. Most do.

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It's too early to tell whether pharmacogenomics, the study of how genes affect a patient's response to drugs, is financially the right thing to do, whether the ROI is there.

"I can't tell you if it saves me money yet," Cote said. However, he said, "I have patients send me patient portal messages, 'You have changed my life by doing this test. For $99 you have essentially changed my life.' Using precision medicine tools we feel empowered as a physician. It feels very doctory."


The long-term impact is that treating patients with the right medication the first time saves money and improves outcomes. It stops the practice of trial and error to determine the most appropriate medication, and prevents the necessity for physicians to switch treatment regimens, which they don't like to do, Cote said.

Long-term, there should be a tremendous cost savings. For example, Cote said, treating depression represents a tremendous cost to the system. Being able to choose the right medication the first time around, "just from an economic standpoint, it's a no brainer," he said. "The ROI for providers is easy; it's patient satisfaction when you change someone's life like that."

Another benefit is adherence compliance. Some patients stop taking their medication either because of the side effects or they don't feel it's working.

Providers using more precise tools can't help but improve their performance measures.

"A lot of payers are grading us on compliance on the first six months of someone taking an antidepressant," Cote said. "I think what we're going to see is HEDIS [Healthcare Effectiveness Data and Information Set] measures for depression go through the roof."

Oncology remains among the largest field for genomics' focus, followed by cardiac conditions and strokes.

For example, Cote said, some patients who have a heart condition can't process Plavix, which is commonly used to prevent heart attack and stroke. Genetic testing can prevent physicians from prescribing the wrong medication, saving the patient from having to undergo catheterization and conceivably saving their life, he said.


Cote began researching precision medicine about five years ago. MMC began its program by ordering molecular tests for select patients to support diagnostic and treatment decisions. They began testing for patients with breast cancer and other cancers more routinely. In addition, they began to explore pharmacogenomics across various specialties.

But the cost for the lab tests was prohibitive for most patients.

"It's really ridiculously expensive, and it doesn't matter how much you know and understand," Cote said. "If you can't get the patients to take the test, it doesn't matter."

Some plans cover the cost, but that hasn't always solved the problem, he said.
Payers are reimbursing for a few diagnoses, but there must already be a diagnosis for a heart attack, for example, Cote said. The cardiologist is looking at preventing a heart attack.

Payer reimbursement, along with rising lab fees, became a cost problem.

"It was hard to find a lab that would keep the price consistently low," Cote said.

He found that a $99 maximum out-of-pocket cost for patients appeared to be the magic number for them to take the genetic test.

"At $100, patients balk," he said.


Once MMC had negotiated acceptable prices for pharmacogenomic lab tests, Cote sat down with Allscripts subsidiary 2bPrecise to learn about the company's software and how it could help bring the test results to the point of care.

They came to an agreement, and last  month MMC and 2bPrecise announced their partnership for a pharmacogenomics platform to integrate test results to clinical information within the EHR workflow.

Implementation of the platform is now underway, with a go-live start anticipated later this year.

"2bPrecise can reference the GEM [the trademarked Genomic EHR Mentor]," Cote said. "We can click on it; what the tool does is to show the patient mutation."

For instance, a physician who writes a prescription for Paxil for a patient who has depression starts typing the name of the medication into the software platform. If the medication is a good match for the patient's genome, the program lights up green. But if the tool gives back a yellow or red warning, there may be problems because of a gene mutation.

"It makes it super easy for provider to prescribe another antidepressant," Cote said. "We used to have to find the report in the computer. It would 10 to 15 minutes per mutation per patient."


Over time, leadership at MMC anticipates expanding areas of precision medicine beyond PGx such as identifying patients at risk for heritable diseases across specialties.

Cote believes as prices down, PGx will seep more into use in primary care nationwide.

Using PGx for population health is still a step away for MMC. Once they get enough patients tested, physicians will look more broadly at the implications of precision medicine beyond the individual patient.

"We're realizing that's the future of medicine," Cote said.

Twitter: @SusanJMorse
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