Skip to main content

Precision Medicine Impact on Chronic Care, Payers and EHR

October 8, 2019

Precision-MedicineThe development of precision medicine is finally being recognized as a legitimate form of treatment offering potentially targeted, personalized interventions and better diagnoses leading to improved patient outcomes. Artificial intelligence and analytics technology are behind these medical advances, while cloud computing and creating alliances with major technology companies offer better access to the huge amounts of data necessary for medical insights and decisions.

Applications in managing chronic and neurological conditions

  • It would not be an overstatement that precision medicine is already revolutionizing the healthcare industry. Although often associated with treating cancer, precision medicine has widened its scope to include applications in neurology, such as Alzheimer’s patients and others with cognitive diseases and conditions.
  • Studies on screening women over age 30 for breast and ovarian cancer-related genetic mutations have shown that testing not only prolongs life expectancy with earlier, better diagnoses but saves money, making this a high priority for the insurance industry. CMS proposed coverage for next-generation sequencing tests able to detect 324 genes and two genomic signatures in certain tumors.
  • Managing chronic disease is crucial, especially among certain high-risk populations, such as elderly or diabetic patients. Targeting at-risk groups through identifying genes predisposing patients to type 1 or type 2 diabetes leads to better interventions, treatments and improved outcomes while reducing unnecessary expenses. The growing use and competency of population health management is consequently motivating interest in precision medicine among prominent healthcare institutions.

Effects on EHR for providers and vendors

With so many changes and developments happening so quickly, providers are finding that their electronic health records (EHR) aren’t able to contain, store and deliver clinical information when needed. Due to inherent design limitations, most participants in a recent survey believe that current EHR systems are simply not suited to handle the complex tasks and storage capabilities that precision medicine requires. The fact is that any health organizations and providers wishing to stay competitive in neurology, cancer care, chronic care and genetic conditions treatment will need to be able to rely on systems vendors, especially larger ones such as Cerner or Epic, for more advanced IT and related products to provide the right information when needed.

Providers, especially smaller practices, who don’t want to wait for their vendors to fine-tune their products, can turn to a qualified billing service with access to state-of-the-art cloud and other tools to assist with records and billing tasks. Doing so eases the burden on your back office staff while ensuring faster, more complete reimbursement – even from previously reluctant payers.

Payer issues with precision medicine

Payers are finally getting on board with precision medicine as it promotes value-based care while lowering overall costs, especially for population groups such as cancer patients, diabetics and others with long-term or critical needs. Traditionally, payers have been slow to commit to reimbursing what they consider unproven or experimental treatments and intervention plans, as well as many still undecided about if and how to reimburse for therapies such as genetic testing.

The American Medical Association (AMA) has recently expressed its frustration about the lag between the implementation of precision medicine interventions that are increasingly demonstrating effectiveness and their reimbursement by reluctant payers. More patients who could benefit from genetic testing or related modalities are often denied coverage by many private and public insurers who continue to set often-outdated clinical criteria or other standards of evidence of efficacy. As a result, the AMA has called the insurance industry to move forward on adopting more updated policies regarding increased transparency about coverage determinants for genetic testing as well as suggest that private payers permit beneficiaries to explain their cases for reimbursement.

Lawmakers and Congress are becoming involved: Rep. Eric Swalwell of California recently introduced a bill called the Advancing Access to Precision Medicine Act would allow states to apply for exceptions to Medicaid payment rules for coverage of whole genome sequencing clinical services for children with medical conditions that may have an unidentified genetic component.

Artificial intelligence, evidence-based medicine and new guidelines

More than a few physicians, especially those in practice for a longer time, may still view the new technologies with a dose of skepticism. After being subjected to ever more restrictive guidelines, protocols, payer reimbursement policies, and compliance requirements many feel as if they are on the way to being cut out of the healthcare picture altogether.
One thing to remember is that these, like any tools, are there to help physicians access the correct amounts of clinical and related data that applies to the situation and patient at the moment. They are intended to enhance the physician’s own instincts and experience for diagnoses and treatment plans with access to images, reference data and provider guidelines.  

When clinical evidence is combined with a provider’s education and experience along with patient demand for more personalized medicine, this creates a bit of a dilemma: when it comes to care, one size doesn’t fit all patients. Unfortunately, current payer guidelines in use have been developed from deliberately abstract data, rendering it one-size-fits-all. In other words, “evidence-based” can only go so far: patients are all individuals. The physician chooses which appropriate path of care and when to adjust it depending on the patient’s response.

The benefits of working with a medical billing and practice management service

Since 2002, M-Scribe has been a leader in the field of medical billing, and practice management services, positioning us to take the lead in helping providers with the intricacies of billing for cutting-edge interventions and services.  Our state-of-the-art systems and highly trained, experienced personnel will ensure that your claims are billed correctly, meeting payer and CMS requirements. In addition, we follow up with payers to see that payment due is made quickly and fairly, for managing your revenue cycle.

Contact us by phone at 770-666-0470 or email us for a confidential assessment of your practice’s needs and revenue goals while learning more about how our additional services can help you remain competitive in the healthcare marketplace.


Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch