Payers wary of covering 'experimental' genetic tests for cancer

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Insurers says genetic tests to identify cancer risks don't fit existing coverage frameworks.

Genetic tests that can identify patients with a higher risk for cancer are a fundamental feature of precision medicine efforts, but the nation’s largest insurers said those tests don’t meet existing coverage frameworks.

Eleven major U.S. insurance companies covering more than 160 million lives told researchers that hereditary cancer panels (HCP) were a poor fit with coverage frameworks because the tests are deemed “experimental,” according to a study published in the Journal of the Comprehensive Cancer Network. Because HCPs include genes that are considered both well-studied and less studied, the entire test is classified as experimental.

Although nearly three-quarters of payers said they understood why HCP tests were appealing to clinicians, just 18% said coverage frameworks should be modified to accommodate them. Many indicated there was insufficient evidence surrounding certain genetic tests and pointed to a lack of clinical utility among HCP tests.

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The Precision Medicine Initiative, announced by President Barack Obama in 2015, has placed greater emphasis on the value of genetic testing, and insurers have faced more pressure to cover genetic tests. Recommendations released by the Cancer Moonshot panel in September included a call for new testing technologies and a national ecosystem for cancer data.

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But researchers said policy experts should consider coverage requirements, and they called for the Precision Medicine Initiative to address coverage barriers, incorporate payer requirements into its research agenda and inform patients of payer recommendations.

“We hope that our findings bring attention to the topic of insurance coverage for cancer panels and contribute to a productive dialogue among various stakeholders on framing an approach to address payers' concerns," Julia R. Trosman, Ph.D, director of the Center for Business Models in Healthcare and lead author of the study, said in a press release. “Many previous studies on reimbursement for genomic technologies, including our own, were focused on barriers to coverage. We are encouraged that the present study also identified opportunities that could be pursued to mitigate barriers.”

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