ASCO issued a statement Sept. 6 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.”
Cigna is the first national health insurer to require patients seeking genetic testing for breast cancer, colorectal cancer syndromes or Long QT syndrome to undergo genetic counseling in an effort to reduce inappropriate use of the tests, which each cost thousands of dollars. The insurer also says inappropriate use of the tests can lead to unnecessary medical services and undue anxiety for patients and their families. The policy goes into effect Monday.
Under Cigna's new policy, it will pay for counseling provided by a board-certified genetic counselor or a clinical geneticist, but not for counseling provided by a physician or a healthcare professional employed by a lab that offers genetic testing. Telephone consultations also will be available.
The groups opposing Cigna's policy argue that pre- and post-test counseling, which can cost $50-$100, should be covered if it's provided by the patient's physician. They say the requirement may act as a barrier for patients in need of genetic testing.
ASCO said that oncologists and oncology nurses are well qualified to provide genetic counseling. It also said Cigna's policy could result in patients opting out of genetic testing because of the need for an additional referral and increased out-of-pocket costs.
While counseling for patients receiving BRCA testing must be covered by insurers on a first-dollar basis under the Patient Protection and Affordable Care Act, patients can face cost sharing if they are tested for colorectal cancer syndromes and Long QT syndrome.
A Cigna spokesman said the company declined to comment. Dr. David Finley, Cigna's national medical director for enterprise affordability and policy, previously told Modern Healthcare that “a lot of (genetic testing) is valuable, but a lot of it is not valuable. We owe some responsibility to our customers to help them decide.”
Dr. William Harb, a Nashville colorectal surgeon, said, “This is going to inhibit patients being tested for inherited cancer syndromes. It introduces another hurdle that patients have to go through.”
Harb and Linda Bruzzone, president and founder of Lynch Syndrome International, say there is a shortage of certified genetic counselors in the U.S. and the waiting time for genetic counseling in some parts of the country can exceed three months. Patients with this gene mutation often choose surgical treatment options, such as a colon resection or a hysterectomy, and delays in counseling could further delay treatment decisions.
“Counseling is beneficial, but we believe that it should be a patient choice,” Bruzzone said.
Alice Lara, president and CEO of the SADS (Sudden Arrhythmia Death Syndromes) Foundation, said it's better for patients at risk for Long QT syndrome to meet with genetic counselors who specialize in cardiac syndromes. But there are fewer than 100 certified counselors with this specialty in the U.S. and some do not work full time, she added. “It should be a physician working with a qualified genetic counselor who is cardiac-based,” Lara said.
Lara said she also would prefer that specialty genetic counselors and cardiologists counsel Long QT syndrome patients rather than having general genetic counselors do this.
But most physicians and patient advocates support the use of genetic counseling as a tool to guide patients through a diagnosis and also prevent inappropriate utilization of costly genetic tests, which can lead to anxiety and unnecessary procedures for patients.
Cigna estimates that inappropriate testing for the BRCA genes, which can cause breast cancer and other cancers, occurs about 20% of the time. That test is “being overordered, overused and misused,” said Dr. Robert Nussbaum, chief of medical genetics at UCSF Medical Center in San Francisco.
Unlike a Long QT syndrome diagnosis, which indicates the need for specific treatment options such as beta blockers and the avoidance of certain other medications, the next treatment step for patients who receive BRCA testing can be unclear.
“We absolutely believe that patients need access to better tests at lower costs,” said Karuna Jaggar, executive director of Breast Cancer Action. “At the same time, we want to ensure that … those tests are appropriately validated.”
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