Rethinking the Approach to Genetic Testing and Treatment Coverage

Updated on May 9, 2023

Genetic testing and gene-based treatment have become an essential part of patient-centered healthcare, with new tests and treatments entering the market every day. With the right tests and interpretation, providers can identify patients at risk and help them pursue the most appropriate screening plan to detect serious medical conditions earlier, identify the most efficacious treatments faster, and avoid therapies that may be less effective based on their genetic test results. Although the ability to incorporate genetic tests and treatments into everyday healthcare is expected to be a gamechanger, it can be challenging to keep up with the rapid developments in this space to ensure the most benefit from new and emerging advances. 

This is especially true for health plans. Although some health plans have yet to see a significant influx of requests for coverage of genetic testing and genomics-based therapeutics, the demand and complexity of requests for these procedures is expected to continue to grow and could expand nearly overnight given the pace of innovation and FDA approvals. 

Even with a small number of requests, the financial impact of these tests and treatments can be substantial. Not only are genomics-based tests and therapies some of the most expensive on the market, but the downstream carepath after genetic testing needs to be considered as part of the equation. Studies have shown that even if genetic testing is pursued, individuals may proceed with contraindicated procedures if the results are not incorporated effectively into the care plan. This can lead to increased risks for patients and costs beyond the cost of testing itself.

Unfortunately, health plans have historically taken a reactive approach for coverage decisions for genomics-based care, considering each test individually when it’s ordered and deciding coverage one test or code at a time. In many cases, a health plan’s genetic testing coverage guidelines focus narrowly on individual tests or therapies and don’t have coverage criteria that encompass all related tests. This limits the plan’s ability to keep pace with new tests entering the market, even if the new test may be more effective than those tests and treatments that are currently covered. This is especially true for policies that are only reviewed on an annual basis. 

So how does a health plan know if it has an outdated, reactive approach? Here are 5 signs to look for and questions to ask:

Numerous coverage policies focused on single genetic tests or markers. Do ordering providers need to check multiple coverage policies to understand the coverage of genetic testing for the patient encounter? This may point to a narrowly focused set of coverage policies. Health plans should consider revamping their genomics coverage policy to include related conditions or whole clinical testing categories together, so the policy and guidelines encompass all related tests, newly emerging tests, and the latest evidence-based testing regimens in one place. 

Coverage policies do not reflect current clinical evidence.Are members and/or providers regularly requesting tests and treatments that the health plan’s medical reviewers aren’t familiar with? This may be a sign that policies aren’t current. If a health plan doesn’t have a current mechanism for incorporating the latest evidence or new tests and treatments into the coverage policy without an off-cycle policy update, it may struggle even more to keep genomics policies up to date. And if the genomics policy review and updating process is based on information that is more than a year old, chances are it is not meeting the needs of members and healthcare providers. 

Increased spending on unnecessary genetic testing and associated downstream procedures. Is spending on genomics testing and therapies uncontrollably increasing year over year? Is the volume of genetic testing and treatment decisions overturned on appeal rising as well? These indicators could point to out-of-date policies and inconsistent policy decisions which lead to unnecessary spending and avoidable waste.  

Growing provider abrasion and member frustration. Is the appeal volume related to genetic testing and therapies rising year over year? Are the number of member and provider grievances related to coverage of these procedures going up as well? Increases in these two areas signal greater member and provider frustration, which could have impacts to the health plan’s reputation, provider network, and member retention efforts. 

Regulatory and accreditation pressures. Inconsistent coverage decisions may have regulatory and accreditation implications. If a health plan is experiencing these pressures, then embracing a more proactive approach to genomics benefit management that ensures quality, consistency, and timeliness may be important. Improving the quality of the plan’s approach to coverage of genetic testing and therapies may provide an opportunity to show quality improvement efforts to meet accreditation requirements and avoid future corrective action plans.

To keep up with the speed of change in genetic testing and treatments, it is time for a mindset shift. Instead of relying on reactive measures, health plans should consider a strategy that structures policy, processes, and approach to be more proactive. This can ensure the right coverage decisions are reached faster, easier and more reliably, reducing risk and increasing the likelihood that spending on genetic tests, treatments, and associated procedures leads to positive health outcomes for members.

Kelly Athman CGC Sr. Director of Medical Affairs at InformedDNA
Kelly Athman

Kelly Athman, CGC, is Sr. Director of Medical Affairs at InformedDNA.