Cigna re­quires ge­netic coun­sel­ing

New pol­icy aims to re­duce in­ap­pro­pri­ate test­ing of at-risk pa­tients

Modern Healthcare - - LATE NEWS - Jaimy Lee

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.”

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