Genomic Medicine: To cover or not to cover? Top questions you should be asking

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The world of genomic medicine and genetic testing is wildly building momentum.  With tests to determine reproductive issues, prenatal testing, and hereditary cancers, the theory of being able to predict the probabilities and risks before the onset of symptoms is very appealing.  The marketplace currently boasts over 75,000 such genetic tests currently available.  But with new tests emerging into the marketplace daily (some estimate 10 new tests per day) there are a lot of questions surrounding whether they should be covered. And with things happening so quickly, the science has been inconsistent in many of these tests, with reports of false positives.  With such a rapidly increasing marketplace, it’s difficult for employers to know which tests are beneficial to their employees and what should be covered.

Interestingly, the Northeast Business Group on Health (NEGBH) has come up with a set of questions that employers should use to weigh which tests they might consider covering. 

 “Employers are beginning to take a heightened interest in genomic medicine,” said Candice Sherman, CEO of NEBGH. “They clearly want to better understand genomic medicine and know what guidelines they should follow in making relevant benefit decisions. We developed this guide to provide a solid orientation on genomic medicine and give employers and HR a good place to start.”

Here are the questions they suggest using to better understand how their individual employee health plans approach the coverage of genomic medicine:

1. What is currently covered and not covered when it comes to various genomics-based testing and treatments?

2. How do these policies align or differ with the policies of other health plans?

3. What is the cost of various tests or treatments that are covered and not covered, and what is the cost for the patient?

4. Will a test or treatment improve the health of the patient or the patient’s child? What is the impact on quality of life?

5. Are there immediate or longer-term projected savings?

6. Does your plan require a swift prior authorization process for genetic prenatal testing during the first or second OB visit?

7.  Which clinical or review body does your plan follow in deciding whether to cover a genomic test or treatment?

8. What metrics does your plan use to evaluate a test/treatment?

 Employers should also consider these questions about their own company:

1. Is your company a trendsetter when it comes to benefits or do you tend to follow standards in your industry and among your peers?

2.  To what extent do you want to reward specific behaviors that could lower costs such as genetic screenings for cholesterol?

3. Are you likely to opt for a generous coverage policy for prenatal genetic testing to avoid complaints among prospective parents?

4.  When it comes to cancer, for example, how big a factor is cost in deciding what to cover?

5. If your health plan does not cover a specific test ordered by an employee’s doctor, how do you want to handle that physician’s request?

While the new discoveries in genomic medicine are very promising, these are early days.  Research and time will test how our approaches change, but it’s important to keep well-informed on these emerging tests and other coming changes to the health and wellness industry.

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