Should insurers require counseling for genetic testing?

Critics, supporters debate Cigna's new policy

Physicians and patient advocacy groups are divided over a new Cigna policy that requires certain patients to obtain counseling before receiving genetic testing, Jaimy Lee writes in Modern Healthcare.

Background on the new policy

In a first-of-its-kind program, Cigna on Sept. 16 will begin requiring genetic counseling for beneficiaries seeking genetic testing for breast cancer, colorectal cancer syndromes, or Long QT syndrome.

For example, Cigna enrollees who want to be tested for BRCA mutations—which are linked to a heightened risk of breast cancer in about 5% of patients—would meet with a genetic counselor to discuss whether testing is appropriate based on their family history. The insurer would then render a coverage decision for the test based on the counselor's recommendation.

The new policy is intended to curb inappropriate utilization of genetic and molecular diagnostic testing, which U.S. health insurers spend millions on annually. In addition, Cigna officials say they want to avoid some of the anxiety and physical harm that unnecessary testing can cause. 

Although counseling for patients receiving BRCA testing must be covered by insurers under the Affordable Care Act, Modern Healthcare's Lee notes that patients can face cost sharing if they are tested for colorectal cancer syndromes and Long QT syndrome.

What critics say

The American Society of Clinical Oncology (ASCO) and advocates for patients with sudden arrhythmia death syndromes and Lynch syndrome, which causes colorectal cancer and other cancers, oppose Cigna's new policy.

In a statement issued last week, ASCO wrote that it "opposes this new policy as it has the potential to negatively impact the care of cancer patients by serving as a barrier to the appropriate use of genetic testing services. It also prohibits patients from seeking this service from their own providers."

Under the policy, Cigna will pay for counseling provided by a board-certified genetic counselor or clinical geneticist. Critics argue that pre- and post-test counseling, which can cost between $50 and $100, should be covered if it's provided by the patient's physician. ASCO says that the need for an additional referral and increased out-of-pocket costs may encourage some patients to forgo testing.

Officials from the Lynch Syndrome International also note that there is a shortage of qualified genetic counselors in the United States. Oftentimes, patients must wait for more than three months before receiving a genetic test.

What supporters say

However, Lee writes that a majority of physicians and patient advocates support the use of genetic testing as a means to avoid excess costs related to the procedure, as well as anxiety and physical harm to the patient. Cigna estimates that about 20% of BRCA tests are ordered inappropriately.

Karuna Jaggar, executive director of Breast Cancer Action, points out that subsequent treatment steps for patients who receive BRCA testing are oftentimes unclear. "We absolutely believe that patients need access to better tests at lower costs," she says, adding, "At the same time, we want to ensure that… those tests are appropriately validated" (Lee, Modern Healthcare, 9/11 [subscription required]).

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