We’re in the infancy of the genomic revolution. Today, more than 70,000 genetic tests exist, many with the potential to make life-changing improvements in health. However, even with all these scientific breakthroughs, we understand the functionality of less than two percent of our genome – with decades of new discoveries to unravel. That leaves payers and providers struggling to understand how to incorporate genetic advances appropriately.
Consider that one out of every three genetic tests is misordered. And, as expected, when the wrong test is performed, you don’t get the answers you’re looking for. The impact is reflected not only in the cost of an unnecessary test, but also in the decisions made based on the test result: surgical, therapeutic, and surveillance decisions. Each of these actions has a financial and emotional cost.
How can payers better ensure that decisions around genetic testing and therapies are based on evidence? Our experience points to three key strategies.
1. Deliver genetics expertise to clinicians at the point of care. With so many genetic tests and therapies on the market, it’s not realistic to expect payers or providers to have the in-house expertise needed to determine whether a test or therapy is clinically indicated and medically appropriate for a particular patient. A decision-support model for genetic testing products – provided within the framework of a prior authorization process and backed by a multidisciplinary team covering all genetic subspecialties – is a value differentiator for both payers and providers.
Most prior authorization processes for genetic testing are designed to simply provide a “yes” or “no” answer to requests. These answers typically do not include decision support features that could help pinpoint whether the patient could benefit from a different test based on the clinical scenario. The reason: Payers usually do not have the level of resources needed to provide this type of support, such as a team of genetics specialists on staff.
However, when payers invest in outsourced genetics specialists expertise to drive better decisions at the point of care, the specialists can not only provide instant approval for clinically relevant tests, but also can hold conversations with physicians in real time to support more informed decision making. It’s an approach that eliminates binary yes-no decisions around genetic testing that could result in unnecessary denials, unnecessary appeals, and more importantly, delays in patient care.
At InformedDNA, our experience with one national payer shows that in 25 percent of these conversations, there is consensus that a more clinically appropriate test is available than the one originally ordered and ordering providers welcome genetics expert support.
2. Develop best-in-class medical policies around genetic testing and therapies. When it comes to developing medical policies for genetic tests and products, payers are challenged to stay ahead of the curve. It isn’t possible or reasonable to expect that payers have a medical policy for each of the more than 70,000 genetic tests and therapies available. However, payers can partner with genetic experts to develop “umbrella policies” bytype of genetic tests and therapies, such as those for hereditary cancer, hereditary heart disease or reproductive genetics that can be more readily kept current. They can also leverage genetics expertise to create a list of “never allowed” tests that can be automatically denied based on lack of clinical evidence.
Spinraza is a key example of a gene therapy for which deep genetics expertise is required to establish medical necessity. Spinraza can improve motor and respiratory function in certain pediatric and adult patients who suffer from spinal muscular atrophy (SMA), a neurodegenerative disease caused by mutations in the SMN1 gene. However, fewer than half of patients who suffer from SMA are appropriate for this therapy currently; for example, it is not yet known whether children on ventilators will benefit from Spinraza. Meanwhile, the costs are high: $750,000 in the first year and $375,000 per year for the rest of patients’ lives.
This is an instance where a strong genetic benefits management program can help payers assist providers in navigating the complex medical decision-making process. By providing genetics expertise to physicians at the point of care, physicians will be better able to make treatment decisions based on clinical evidence. Availability of genetic counselors also is vital in explaining to patients and their family members the reasoning behind an adverse determination, especially when such a decision carries a powerful psychological impact.
3. Require genetic counseling as part of the medical necessity determination process. Genetic counseling empowers members to make informed medical decisions about some of the most complex genetic tests with signficant impact on patients and family members. It also improves member relations while avoiding unnecessary medical spend. At InformedDNA, our work with one national payer found that when genetic counseling is a required component of the medical necessity determination process, one out of five individuals who receive counseling with proper informed consent decide not to pursue genetic testing.
Collaborating for greater value
The pace of advancement in precision medicine is breathtaking. Each day, 10 new genetic tests are introduced, yet only a fraction of patients who could benefit from these advancements have access to them. And, too often, those who wouldn’t benefit from genetic tests and therapies end up undergoing testing unnecessarily because of a lack of expert guidance. Developing strong partnerships with genetics experts helps ensure decisions based on clinical evidence to guide the use of genetic tests and therapies – and significantly improves the patient and provider experience.
To learn more about our Genetic Benefits Management™ services for health plans or our Genetics Services Program™ for health systems and hospitals, please give us a call at 800-975-4819; send an email to email@example.com; or, just fill out the form below and we’ll get in touch shortly.