Posts Tagged coverage
Posted by Darshana V. Nadkarni, Ph.D. in Biotech - Medical Device - Life Science - Healthcare on August 19, 2013
Mark Zubiller, VP of Decision Management at McKesson, talked about value based medicine by driving better diagnostic decisions through collaborative model, aligning labs, clinicians, and payers, at www.bio2devicegroup.org event.
Molecular diagnostic tests identify molecular and genetic markers for an individual patients that help determine potential benefit from a specific, targeted therapy. Molecular diagnostic tests have become a big buzz word but the area is fraught with challenges. There isn’t a lot of clinical evidence that support many of these tests which are often based on extreme of a diagnostic marker, so there needs to be more data churning to demonstrate clinical utility of the data. Second, there is limited point of service information. Only 20% of molecular diagnostic tests on the market have evidence based guidelines today, although 75% of the providers believe that patients in their practice would benefit from having a genetic test. As new tests continue to emerge, physicians cannot keep up with information about newer tests and their efficacy. Third, many of the tests are unidentifiable. There is no catalogue for identifying the tests, coding information is nonspecific, and payers do not have consistent way to code and pay for these. Payers require clinical utility for coverage. This often leads to denials and reapplications and generates a lot of frustration for everyone involved. Finally, this results in increased paperwork and payer scrutiny.
Currently, market does not have a way to address this challenge and it is stuck between innovation and execution. There is a great deal of system fatigue, on account of increasing administrative burden, reform compliance etc. but while innovation is greatly needed, it would bring reimbursement shifts, additional administrative challenges, and a need for collaboration among the stakeholders. Payers, labs, and providers essentially share the same challenge of ensuring that patients get the right care at the right cost, without increased administrative burden. Existing traditional payer programs operate in silos and do not have a way of engaging providers. They require expensive manual resources and are struggling with administration, transparency, and consistency. Lack of collaboration exerts a huge financial burden on both the providers and the payers. Providers spend $31 billion annually and payers spend $74 billion annually that could be saved, with greater collaboration.
Explaining the McKesson value based care model, Zubiller said, it means “balancing value-based reimbursement with value-based care delivery at the point of care. As the patient care progresses from care selection to care plan to network selection to reimbursement, point of care decisions happen at each stage that impact cost, care, and value. Earlier and better decisions would greatly reduce cost, improve care, and provide better value, said Zubiller. A value based diagnostics strategy has to be based upon collaboration between labs, payers, and providers for identification of tests, for determination of cataloging and coverage, for consistent evidence based payer and lab policies, for decision support rules integrated into EMR, and for sophisticated performance data analytics for payment.
The talk was followed by Q&A. Explaining the strategy, Zubiller said, McKesson is a business that works with health care stakeholders in every setting and is therefore taking the lead to chart the course towards a stronger more sustainable future, for the entire industry. McKesson is a leading provider of enterprise information technology solutions, including software, services, automation, and consulting to hospitals, physician offices, imaging centers, home health care agencies, and payers. With strategic use of IT solutions to bring greater connectivity in the healthcare ecosystem and by leveraging its credibility to bring the stakeholders to the table for collaborative dialog, McKesson hopes to lead implementation of value based care model that would be a win-win solution for payers, providers, labs and for patients.