A recent study found more than one-third of genetic tests ordered by a single medical center during a three-month period were misordered, resulting in $20,000 in unnecessary cost.
At InformedDNA, we have seen a similar pattern across the many health systems we work with. If all US medical centers experienced this level of genetic test misordering, that would amount to about $400M in inappropriate testing annually. Provider knowledge deficit concerning genetic testing is a major cause of this issue, which is why decision support should be a critical element of the selection and prior authorization processes.
Today, physicians have nearly 70,000 genetic testing products from which to choose, and new genetic tests are released at a rate of 10 per day. Ten years ago, a RAND survey found physicians felt “woefully underprepared” to utilize genetic testing in their practices. Today, the rate at which new products are introduced makes it nearly impossible for physicians to keep up with the science that informs whether genetic testing is required, what type of test to order and how to interpret results.
Payers often require prior authorization for genetic testing, which touches most medical disciplines. However, there are challenges associated with prior authorization—for both payers and providers:
• Prior authorization requirements pose significant administrative burdens for providers and payers, and policies vary by payer. In response, six healthcare industry groups recently announced their shared commitment to work together to alleviate this burden, such as by reducing the number of healthcare professionals, services and tests subject to prior authorization.
• Most prior authorization processes are designed to simply provide a “yes” or “no” answer to requests. They typically do not include decision support features that could help pinpoint whether the patient could benefit from a different test based on the clinical scenarios described and the patient’s background. The reason: Payers usually do not have access to the resources needed to provide support, such as a team of genetic counselors.
• There is significant opacity around the current procedural terminology (CPT) codes assigned to genetic tests, with fewer than 200 CPT codes covering nearly 70,000 genetic testing products. This makes it difficult for providers to bill for tests or payers to identify which test has been ordered. It’s a challenge that is unique to genetic testing, and it’s one reason why prior authorization is recommended for all genetic tests.
• The level of intervention for genetic tests varies. Some tests are fast-tracked for approval because they typically are ordered correctly. Others, such as tests for hereditary cancer mutations or tumor profiling, undergo a more rigorous approval process.
What is needed is the availability of deep subject matter expertise—both at the point of care and during the prior authorization process—to support appropriate utilization of genetic testing.
There are four ways providers and payers can better support informed decision-making around genetic tests at the point of care.
Develop partnerships between payers and genetic counselors. With rapid advances in genomic science, it isn’t realistic for payers to have a policy in place for each genetic testing product available. Meanwhile, it’s clear providers both need and want expert-level support in determining when a genetic test may be appropriate as well as which test to order. By partnering with genetic counselors, payers can more effectively design and implement a prior authorization program for genetic testing, and can give providers the support they need to make evidence-based decisions. Genetic counselors also can assist in evaluating the quality of new tests and in navigating sensitive conversations with patients.
Provide access to “curbside consults.” Physicians who have questions regarding whether to order a genetic test needn’t wait to undergo the prior authorization process to obtain answers. Some companies offer “geneticist on call” services for health systems and physician practices, enabling physicians to explore whether genetic testing is recommended based on the patient’s unique history and clinical scenario and, if so, which testing option to pursue.
Design patient questionnaires that can identify those who would benefit from genetic counseling. For example, some health systems offer a “triage questionnaire” to newly diagnosed cancer patients to help determine which patients should be referred for genetic counseling or testing.
Invest in telehealth access to genetic counseling. Genetic counselors are a scarce resource. A telehealth model for genetic counseling provides patients and providers with equal access to genetic counselors, no matter where the practice or health system is located. Use of a telehealth model also helps providers maintain stewardship of their patients’ care across the continuum of care.
Navigating a New Era in Medicine
The advancements taking place in genomic medicine are exciting, but at a time when celebrities are sharing their experiences with genetic testing, it can be difficult to separate the evidence from the hype. With the right decision-support resources and prior authorization programs in place, payers and providers will be able to achieve their shared goal: providing the right test for the right individual at the right time.
David Nixon is Chairman and CEO of InformedDNA, the nation's largest independent provider of genetics expert services.
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