The Intersection of Value-Based Care, Precision Medicine at Intermountain

At this week’s National Human Genome Research Institute meeting on “genomic learning healthcare systems,” an Intermountain Healthcare executive described the link between value-based care and precision medicine.

Howard McLeod, PharmD, executive clinical director of precision health for Utah-based Intermountain Healthcare, initially spoke about the learning health system approach at Intermountain.

McLeod said that for a learning health system to develop, an institution has to want to learn and iterate and improve. “That's one of the big keys. And the second, there's a big difference between employee positions and affiliate positions,” he said. “And we've seen even within Intermountain, the learning happens differently, depending on the engagement with the institution.”

Intermountain is an integrated health system that has 33 hospitals and almost 400 clinics distributed across nine states. It is doing a lot of value-based care, but also a lot of fee for service. With the recent merger with the SCL Healthcare system, Intermountain has both a large Cerner and a large Epic presence, “and no, they don't communicate very well with each with each other,” he said.

Intermountain Precision Health involves about 200 caregivers distributed across the Intermountain footprint. A lot of the precision medicine work is in the context of value-based care, McLeod stressed. “A lot of the learning is how do we optimize value as an endpoint as we're going forward.”

McLeod gave examples where because Intermountain is focused on total cost of care, genomic testing and innovative approaches are encouraged. He spoke of a man with metastatic lung cancer. He's run out of options; there's no clear next option based on national guidelines or FDA approvals. He said he wants some sort of treatment. Genomic analysis identifies something that might be clinically actionable, but there are no guidelines for that. It goes to a molecular tumor board, which identifies eligibility for a particular trial. That information is used to influence the discussion with the insurance company to pay for that unusual situation — in this case, melanoma therapy for lung cancer.

“With this sort of model, a lot of the value is brought by the therapeutic evaluation by the tumor board,” McLeod said. “It's not adequate just to have genomic data. You need to have the interpretation of that data that goes hand in hand with the laboratory piece in order to go forward. We've shown data and others have shown data, where not only is there about a doubling of survival of these patients who get a precision approach versus a standard approach, but there's a cost savings. And $734 may not seem that big of a cost savings, but this is total cost of care, because we have the entirety of this patient's medical care. So their total cost of care is impacted $734, favorably, when they have precision medicine. Well, that's per patient, per week. So you then can scale that out to about an $80 million savings that occurs per year in our health system. That's the sort of data where we have genomics for clinical reasons, get the economics within our system, and then turn that back into growing the application of genomics.”

McLeod also spoke about work at Primary Children's Hospital in Salt Lake City. It has identified a number of different examples where genomics helped identify therapy options. One example was a child who had seizures and 31 hospitalizations by the time he was three years old. “We spent $1.5 million on his care. A rapid whole genome identified a vitamin B six-processing gene mutation. They started him on high doses of over-the-counter vitamin B six, and he has not had a seizure since, and it's been several years now. If we're owning the cost of care, we'd rather spend $13,000 than $1.5 million, even if it's a small number of cases that are coming through. Learning from the clinical situation and having the economics driving more care, because we see the total picture, is an important part of it,” he said.

The question of whether the savings are applied is a really important part of being a learning health system, McLeod said. “The clinical care is what drives us to do it in the first place. But often the direct reimbursement may not be adequate. But the savings is being held by others within the health system, and when that's taken into account, we can make much better decisions for the entire health system.”

In the meeting discussion following McLeod’s presentation, it was noted that the most advanced precision medicine programs tend to be at integrated health systems such as Intermountain and Geisinger, where the insurance arm is more closely aligned with provider groups.

Another challenge is spreading this type of innovation across such a large footprint. “As I mentioned, we have 33 hospitals and 400 clinics,” McLeod said. “There's a large diffusion of innovation that occurs. On average, it's about 17 years, according to the literature, before innovation is fully used across these systems. And geography is a major impact on the level of diffusion. Many of our centers are in small places that don't necessarily get visited by the drug rep or by the equipment rep. So we have a lot of activity now making sure those 33 hospitals are equipped to administer precision medicine, and to be the sounding board for the 400 affiliated medical centers that are distributed across the states. We want to make sure a small clinic in Wyoming can have access to precision medicine expertise through telemedicine and other sources, rather than an approach where we do things in our major centers and then everyone else is just out of luck because they went to the wrong place.”