Health insurers are reluctant to pay for experimental or unproven medical procedures and drugs. And in most cases that makes sense; whether its apricot pits for cancer or artifical cartilage, until there is proof that the treatment will positively impact the condition, obtaining that care could harm the patient, or provide no benefit, while costing the insurance company (and therefore its policyholders) lots of money.
That long standing norm has required insurers to staff medical committees , also known as P&T committees, whose function is to assess new procedures and determine the insurer’s coverage policy. These committees determine if the treatment is covered in all instances, for specific diagnoses, only after other therapies have been tried, or not at all. And in my experience the committees have done their jobs well, diligently, and fairly.
Personalized medicine, aka gene-based therapy, has long stood just outside the committees’ meeting rooms, rarely poking its nose in but nonetheless a very real, and very shadowy presence. The door is about to open, forever altering the size, role, staffing, and reach of these committees. The knock is coming from a beta blocker, Bucindolol, which appears to work quite well for a few people and not at all for others. Early trials were terminated when it seemed the drug did not work nearly as well as others. Now, evidence is emerging that the drug is effective for a segment of the population with a slightly different genetic makeup.
This is the kind of information that will lead to a transformation of the P&T committee, benefit design, medical ethics and likely utilization review. Committees will become larger, require deeper knowledge of genetic medicine, and likely become even more tightly integrated with the medical management department.
And that’s a good thing.
Jul
11
