Clinical laboratories and pathology groups serving Cigna beneficiaries can expect to see new requirements for genetic tests used to diagnose breast cancer, colon cancer and long QT syndrome
Effective this week, Cigna (NYSE: CI) in Bloomfield, Connecticut, is implementing a new program that requires genetic counseling and pre-authorization for certain genetic tests. This is an important development and clinical laboratory executives can expect to see other health insurers take similar steps.
Cigna wants to control costs and improve the appropriateness of ordering expensive genetic tests. It will start with tests for three conditions and may require counseling for other types of genetic tests if this program is successful. Industry observers expect other health insurers will follow Cigna’s example and also require genetic counseling for a compelling reason: all insurers recognize that more than 50% of all genetic tests may be ordered inappropriately, experts say.
The Dark Report Provided Information About Cigna’s New Program
Starting on September 16, Cigna will require patients to undergo genetic counseling before it will approve genetic tests for breast cancer, colon cancer, and long QT syndrome (a rare heart condition). Dark Daily’s sister publication, The Dark Report, was first to provide detailed information on Cigna’s new program of pre-authorization and genetic counseling. (See The Dark Report, “Cigna Program Addresses Genetic Test Utilization,” August 19, 2013.)
For its Genetic Testing and Counseling Program, Cigna contracted with InformedDNA of St. Petersburg, Florida, to provide genetic counseling services to Cigna customers over the telephone. InformedDNA also will advise Cigna about emerging tests, Cigna said when it announced the program on July 23.
A number of health insurers have policies to manage genetic testing, such as requiring pre-authorization, said Amber Trivedi, a genetic counselor and Senior Vice President of Provider and Client Services for InformedDNA. To date, Cigna is the only national insurer to require genetic counseling before testing, she added.
Startling Growth in Volume of Genetic Testing in United States
Cigna’s actions come as a direct result of the astounding growth in both the number of genetic tests and the volume of these tests ordered by physicians. Cigna and other health insurers are concerned about rising costs of molecular diagnostic assays and genetic tests. Few pathologist and medical laboratory managers are aware of exactly how much money insurers are paying to reimburse claims for genetic tests.
It was in 2010 when UnitedHealthcare (NYSE: UNH) published a study that estimated that spending on genetic tests had already reached $5 billion per year. UnitedHealth projected that, by 2020, annual spending on genetic testing would increase to $25 billion!
In his interview with The Dark Report, David Finley, M.D., Cigna’s National Medical Officer for Enterprise Affordability and Policy, would not disclose the actual rate of growth of Cigna’s genetic test volume. But he did say that the rate of increase in spending for genetic testing is considerably higher than the rate of increase in spending for medical services.
Inappropriate Ordering of Genetic Tests May Exceed 50%
Health insurers know that one way to control the cost of genetic testing is to reduce or eliminate inappropriate ordering. It may surprise many pathologists to learn that as much as 50% or more of the genetic tests ordered by physicians may be inappropriate. From that perspective, health insurers could argue that half—or $2.5 billion—of the $5 billion spent on genetic testing during 2010 was unnecessary and did not contribute to improved patient care.
• the type of genetic tests they order;
• the interpretation of genetic test results; and,
• the medical management recommendations they provide based on the results of these genetic tests.
“Requiring genetic counseling prior to genetic testing helps ensure that patients receive comprehensive genetics risk assessment, precision in testing and interpretation of test results, psychosocial support, and access to current management recommendations, in addition to the expertise of their referring physician,” IM News reported.
Genetic Counseling Can Reduce Inappropriate Genetic Test Orders
When she was interviewed by The Dark Report, Trivedi said InformedDNA has found that 52% of genetic tests may be ordered inappropriately before a health insurer implements any prior authorization. “Further, even with a prior authorization process in place, it may be that the health insurer continues to see that 25% to 33% of genetic tests are ordered inappropriately,” she added. “That’s why health insurers are interested in genetic counseling.
“There is a good reason why this happens,” continued Trivedi. “Typically most doctors are unable to get a detailed family history in the 15 minutes they have for each office visit. Contrast that with the one hour that a genetic counselor would spend with each patient. This session would review the patient’s history and the family history for three generations.”
Indeed, physicians may not be the ideal sources of information about genetic and molecular tests, Finley added. “Oncologists and other doctors know the genetics of the tests they order. But many physicians have trouble keeping up with the latest information on many of the tests available today,” he said.
Opportunity for Pathologists and Clinical Lab Experts to Add Value
Clinical laboratories could step in to advise physicians ordering these tests, particularly those tests that are costly and ordered most often, such as those for breast and colon cancer and long QT syndrome. These three tests “are commonly performed, they have big consequences and they are frequently misunderstood,” Finley said.