Cigna requires genetic counseling
New policy aims to reduce inappropriate testing of at-risk patients
With the use of genetic testing growing rapidly, Cigna Corp. has become the first major health insurer to require subscribers who are at risk for breast cancer, colorectal cancer syndromes or Long QT syndrome and are considering genetic testing to first meet with a certified genetic counselor.
Cigna says this will reduce inappropriate utilization of genetic tests. Experts say testing can cause patients long-term anxiety, lead to unnecessary treatment, and in some cases stop a patient from receiving needed screening.
“A lot of (genetic testing) is valuable, but a lot of it is not valuable,” said Dr. David Finley, Cigna’s national medical officer for enterprise affordability and policy. “We owe some responsibility to our customers to help them decide.”
The policy highlights a cautionary shift in the rapidly growing field of genetic testing. Experts say few physicians have received the training they need to properly interpret test results. And some low-risk patients have pushed for genetic testing, which had led to overutilization in those instances.
“Genetic counseling has been ignored and pushed to the side, but it’s a very important part of this process,” said Dr. Sonia Kupfer, assistant professor in the University of Chicago’s Section of Gastroenterology and Center for Clinical Cancer Genetics.
U.S. payers spend hundreds of millions of dollars on genetic and molecular diagnostic testing each year. UnitedHealthcare has estimated it spent about $500 million on these tests in 2010.
It’s unclear at this time whether other insurers will initiate similar requirements. An Aetna spokeswoman said in an e-mail that Aetna “strongly encourages counseling for genetic tests.”
However, she added, “we have not required genetic counseling as a prerequisite to genetic testing.” She said Aetna covers genetic counseling in accordance with a member’s health plan.
But Rebecca Nagy, a certified genetic counselor and associate professor of clinical internal medicine at Ohio State University, said she expects other insurers to follow Cigna’s lead. “If it’s successful, we’ll see other people follow suit, and I do think it will expand across additional tests,” Nagy said.
Clinicians say that it’s not always clear how best to interpret a patient’s genetic test results. That can lead to more confusion for patients who must deal with implications
“If it’s successful, we’ll see other people follow suit, and I do think it will expand across additional tests.”
—Rebecca Nagy, certified genetic counselor and associate professor at Ohio State University
that include concerns about the stigma of having the disease and what the results may mean for other family members who may also have genetic vulnerability to the disease.
“It can have consequences for patients in terms of their understanding of what a test result means,” Kupfer said.
Genetic tests for breast cancer, colorectal cancer and Long QT syndrome are frequently ordered but can be misunderstood. Finley said the test results can have “profound implications” for patients and their families.
For Cigna enrollees who are seeking testing for the BRCA gene mutations, which are linked to breast cancer in about 5% of breast cancer patients, a genetic counselor first will address criteria such as a patient’s family history as well as explain whether the patient is a good candidate for the test. A Cigna medical director will then render a coverage decision for the test based on the genetic counselor’s recommendation.
Finley said about 20% of BRCA tests are ordered inappropriately. Until recently, the only available tests for the BRCA genes cost about $3,340. Pre-testing counseling costs about $75 to $100, while post-test genetic counseling runs roughly $50 to $100.
The cost of BRCA testing has been a concern for healthcare providers and patients. The issue was also raised in a recent U.S. Supreme Court gene patenting case. The court ruled that Myriad Genetics, the developer of the only BRCA tests in the U.S., could no longer prevent other laboratories from conducting BRCA tests based on their patents of naturally occurring segments of human DNA.
A study by researchers in Florida published this year in the journal Genetic Testing and Molecular Biomarkers found that involving genetic professionals in BRCA testing can boost cost-effectiveness and enhance patient care. “Thus, key components to realizing the benefits of genetics and genomics innovations include expansion in access to genetics expertise,” the researchers concluded.
Cigna’s new policy, which goes into effect Sept. 16, will require patients to pay deductibles, copayments and co-insurance based on their health plan.
The Patient Protection and Affordable Care Act, however, requires insurers to cover genetic counseling for BRCA testing as a preventive service with no patient cost sharing. Genetic counseling for colorectal cancer and Long QT syndrome testing will be subject to cost sharing.
When asked if Cigna’s genetic counseling requirement—which will lead to out-ofpocket costs for patients seeking genetic testing for colorectal cancer syndromes or Long QT syndrome—could deter patients from seeking counseling or testing, Finley said, “It’s possible for a period of time that will happen.”
But, he added, that “more and more doctors and more and more patients will realize that the service is well worth it.”