AMA: Payers must adopt more consistent coverage policies for genetic tests, therapeutics

The American Medical Association wants payers to cover genetic tests and precision medicine more consistently, arguing their current practices may hinder patient access to cutting-edge tests and therapeutics.

Currently, there is significant variation between public and private payers when it comes to their evidentiary requirements for covering genetic tests and services, according to a report reviewed by physicians gathered at the trade group’s interim meeting in Honolulu, Hawaii. Plus, different insurers might review the same evidence yet reach conflicting conclusions about medical necessity and coverage of these services, the report noted.

"As a result, access to this next generation of clinical testing services is often limited,” said AMA Board Member William E. Kobler, M.D.

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The AMA therefore voted to adopt new policies that encourage payers to adopt better, more transparent processes for coverage and payment determinations for genetic tests and precision medicine.

To accomplish that, payers should involve a variety of stakeholders—including genetic/genomic medicine experts and relevant national medical specialty societies—and provide opportunities for comment, review and meaningful reconsiderations of coverage decisions, the AMA said.

Payers should also describe the evidence that they’re considering when making coverage and payment decisions, and the methods they use to update that evidence.

For newer genetic tests that are entering the market, the AMA noted, it’s not always feasible to measure their clinical usefulness by traditional approaches like randomized controlled trials. When that is the case, payers must work with test developers and appropriate clinical experts to establish clear thresholds for acceptable evidence for coverage.

Lastly, the new AMA policies encourage payers to assess the value of genetic/genomic tests and therapeutics in terms of their impact on “patients, families and society as a whole, including the impact on quality of life and survival.”

The AMA is not the only organization to take an interest in how payers are handling the rapid rise of genetic testing. A recent report from the consulting firm Arthur D. Little pointed out that as these tests become more readily accessible, payers will face more pressure to reimburse for pricey medications targeted at select population.

However, genetic tests that identify patients’ risk for serious conditions can help them avoid expensive treatments down the road, and the rise of precision medicine will likely allow payers to be more selective when authorizing treatment payouts, the report said.

For its part, America's Health Insurance Plans said in a statement that genetic testing may be covered by health insurers "when deemed medically necessary, with a patient displaying symptoms or at risk of inheriting a mutated gene," adding that "it’s important the genetic test is based on scientific evidence and that the results directly impact treatment decision making." 

However, the trade group also noted that more work is needed to understand how genetic tests can inform treatment and disease management, and how it can improve outcomes. 

"Moving forward, the industry needs to continue work together to on evidence-based solutions, moving more toward value-based care built upon testing and treatments that, today, are most effective, proven and efficient," AHIP concluded.