Original Research and Analysis
Informed Insights™ explores trends and strategies to address barriers as advances in genomics continue to reshape the future of healthcare.
Issue One: Access to Genetics Experts Improves Outcomes of Genetic Testing Prior Authorizations
This issue describes the results of a study conducted by InformedDNA of 3,828 complex genetic testing prior authorization* requests by U.S.-based health plan clients throughout 2018. Analysis of the submitted requests determined that more than half needed further detail for decision-making. When outreach was conducted to the ordering providers of these requests, 70 percent had clinical discussions with genetics experts to exchange relevant information. Based on provider outreach, InformedDNA found:
- Redirection of the original request to a more medically appropriate test was recommended in 27 percent of cases. These modifications occurred when the original request would have been denied based on the initial documentation submitted.
- Approximately 4 percent of requests resulted in withdrawal of the request. Because these requests were likely to result in a denial and possibly subsequent appeals, withdrawals reduced the administrative burden for both providers and plans.
- 97 percent of providers surveyed reported satisfaction with the prior authorization process.
Issue Two: An Inventive Approach to Genetic Test Policy Development for Health Plans
This issue describes InformedDNA’s Coverage Decision Framework, a model that enables health plans to offer members improved access to emerging genetic tests.
The traditional model for developing medical policy has existed for many years—the backbone of this process is evaluation of evidence that a particular service is beneficial and not likely to be harmful, and under which clinical scenarios. However, evidence-based coverage frameworks used for common conditions are not easily applied to rare genetic conditions and newly developed diagnostics. Rapid advances in genomic science and implementation of personalized medicine require new approaches to health plan policy and genetic test evidence review processes.
The framework was designed based on thorough analyses of gaps in existing methods of evidence review. It addresses these gaps by incorporating all relevant factors (drivers) for the evaluation of new genetic tests, thus enhancing transparency and efficiency. The assessment includes details regarding the test platform and validation data, as well as comparison with alternatives and current standards of care.
Issue Three: Pre-Test Genetic Counseling Requirement Benefits Health Plans and Patients
For this issue of Informed Insights, a retrospective analysis was performed of members of one national health plan who had hereditary cancer and who utilized the required pre-genetic test telephonic genetic counseling appointments during 2019. Prospectively recorded demographic information, test results, and decisions regarding genetic testing are presented.
The application of complex genetics in healthcare often requires specialized knowledge and training. Many providers report discomfort with selecting, interpreting and managing genetic tests and results. In healthcare, a team approach benefits patients. And, genetic counselors are valuable team members providing support for providers using hereditary genetic testing to inform patients’ treatment plans.