In part 1 of our interview, Syapse Founder Jonathan Hirsch explains how his team is streamlining operations and improving clinical outcomes with precision medicine tools. In addition to recent projects with the Swedish Cancer Institute and Caris Life Sciences, Syapse has advanced knowledge on the cost effectiveness of precision medicine through a study conducted with Intermountain Healthcare. Here, in part 2, Oliver Wyman Associate Terrance Wallace asks him to share more details of that research and his view on the top drivers and barriers to the adoption of precision medicine:
Terrance Wallace: We have been hearing about genomics and the microbiome for a decade – when will this next wave of innovation become mainstream?
Jonathan Hirsch: In oncology, maternal fetal medicine, and rare and undiagnosed diseases, genomics already is mainstream. Outside of these clinical areas, it depends on the level of clinical evidence available. For example, our partners at UCSF have generated significant evidence supporting genomics as a tool for infectious disease diagnosis and surveillance, and we are in the process of partnering with them to scale up this program. However, much of the popular press around genetics in the last five years has unfortunately been about research activities, propagating the myth that precision medicine has to be about whole genome sequencing. What has gone less commented on is the rapid pace of clinical adoption in the areas I just mentioned. Just look at breast cancer over the past 10 years, where molecular profiling of ER/PR/HER2 status has become standard of care. We’re seeing large community provider systems like Providence, Intermountain, Sanford Health, and others using genetic and molecular profiling in a routine way for cancer care. We’re seeing patients demand genetic testing for cancer risk, and genomic testing once they get cancer. The recent news that Robert Kraft of the New England Patriots donated $20M to Harvard Business School to enable precision medicine business programs is further evidence of the mainstreaming of this science.
TW: What about other clinical areas?
JH: Some clinical areas are a little slower to adopt precision medicine because the clinical utility isn’t clear. For example, is there any genetic or molecular profiling that could be used to detect and treat diabetes? While our collaborator Mike Snyder at Stanford has demonstrated that there may be, more clinical studies are needed. For cardiovascular disease, we know that for certain indications there is evidence it could be applied. At Syapse we think about precision medicine more broadly than genetic and molecular data. Precision medicine at its core is about using both clinical and molecular data to figure out the right diagnosis and treatment decision. Genomic and molecular data is a part of that, but it’s not the only type of data. I think precision medicine should be thought of a little more broadly than just genetic testing.
TW: What are the top adoption drivers?
JH: If you look at oncology, the clinical evidence of improved outcomes is so compelling that health systems and physicians have been adopting this technology rapidly. You’ll see some announcements in early 2016 around very large community health systems that are going all in on precision medicine. While the top driver is certainly the clinical utility improvement, there are also economic and operational drivers. As an example, a key economic driver is engaging affiliate networks. Community health systems with large affiliate networks want to attract and retain patients, and being able to offer advanced care for complex diseases based on precision medicine is a core driver of patient volume. We accomplish this in part by providing a single clinical data integration, workflow, and decision support framework for the entire health system; by including affiliated physicians; and, in part, by disseminating best practices determined by the health system’s center of excellence and collaborators to the physicians in the community. This reduces the barriers to community physicians adopting precision medicine by helping close the knowledge gap. An additional driver is being able to improve reimbursement for genomic testing, and both procurement and reimbursement rates for specialty drugs. We have the capability to centralize all of the data needed to win approval and reimbursement for precision medicine testing and therapeutic options.
TW: How about adoption barriers?
JH: Many people do cite reimbursement of molecular testing and off-label specialty drugs as a barrier to adopting precision medicine. Another barrier is the dissemination of evidence and knowledge to the broader physician community. But, as mentioned, these can be solved for. If you think about major industry barriers, one of the biggest is interoperability. Critical data that you need to enable precision medicine can be locked inside medical records, or, in other cases, the data doesn’t have enough structure to make it useful and actionable. We are doing a lot of work to help solve interoperability issues through our EMR integration technology and our Lab Interoperability Certification Program, but it’s a fundamental issue of the broader healthcare ecosystem. There needs to be a lot of attention to interoperability issues and data structuring issues in order to really move this and many other fields forward.
TW: Is there anything that could be a game changer in terms of driving or hindering adoption?
JH: One clear game changer is a clinical sequencer that can be placed in a hospital pathology department and can be used just like any other lab test is used. That would be a game changer and a lot of people are working on that. We in the industry have been promised that for years, but no one knows when that technology will be ready. You can kind of accomplish that today, but it requires more effort than just purchasing a piece of equipment and validating it. Another potential game changer is CMS coming out with a firm coverage decision for molecular profiling in oncology. At this point, that landscape is very opaque, so a game changer would be announcing broad based coverage of molecular profiling.
TW: What do the next 12 months look like for Syapse? What are your priorities?
JH: Our number one initiative is facilitating data and knowledge sharing among our health system customers to improve care for patients and rapidly build the clinical utility evidence for precision medicine. We are launching, with several of our customers, large collaborative networks to help them share clinical, molecular, treatment, and outcomes data. We recently announced that the center of excellence network assembled by Caris Life Sciences, consisting of 12 cancer centers and 100,000 patients annually, will share data through Syapse. Our second key initiative builds upon initial work we did with Intermountain to understand not just the clinical effectiveness but also the cost effectiveness of precision medicine in cancer care. We found that total cost of cancer care on a per-patient basis was held stable or slightly decreased when precision medicine was incorporated. Drugs and testing were more expensive, but Intermountain saved money in other ways primarily due to reduction in readmission and hospitalizations. In 2016, we will be working to scale up those programs with other health systems to start understanding the cost impact of precision medicine. The goal is to more definitively understand whether precision medicine really does cost more or whether it will hold costs stable or even reduce costs.
TW: What should leaders be thinking about that is NOT on their radar?
JH: Everyone is thinking a lot about population health and moving towards new payment models. Where most health system leaders are not connecting the dots is that precision medicine is actually the easiest way to help transform high cost service lines around an alternate payment model - whether that’s a value-based care model, or bundled payment model, or something else. When you are implementing a precision medicine program, you’re really rethinking the clinical workflows, clinical decision support, care pathways, and resource and cost allocation. This is the perfect opportunity to align the move toward alternative payment models with physicians’ interest in precision medicine. Physicians often react negatively to a move to these alternate payment models, but react incredibly positively towards a move to precision medicine. If you’re the head of a network or you’re the CMO of a health system and you know that you need to move toward these alternative payment models, particularly in oncology care where you’re going to have to have 80% of your patient volume flowing through bundled payments within about four years, precision medicine represents the easiest way to get that done. Health systems that we’re working with - Intermountain, Providence, and others - have embraced that and are very forward looking. I think that philosophy has not yet made it to the broader ecosystem.