It’s easy for health plans to think about genomics as “just another specialty” to manage, much like radiology or cardiology. However, given the dynamic nature of the field and the ever-changing testing landscape with little regulation, genomics must be approached differently when developing clinical policy and enacting utilization management strategies.
Here’s why:
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There are now more than 167,000 genomics tests on the market. Yet there are only a little over 400 CPT codes to represent them. That makes ensuring accurate coding and comparisons of tests against policy and between laboratories complicated and nuanced.
Furthermore, many genomics tests are released for commercial use before there is clinical evidence demonstrating their clinical benefit or comparing them with currently available diagnostic, treatment, or management options. Consequently, health plans often need to develop coverage criteria for genomic tests utilizing far less robust clinical evidence than they typically have for policy development in other medical specialties.
Due to all these intricacies, health plans’ genomic benefits management (GBM) programs face sizable vulnerabilities. Without the help of genomics specialists, it is hard for health plans to manage genomic benefits efficiently and effectively. Now is the time for health plans to evaluate their GBM programs to find the right expert guidance and utilization management support.
Understand current GBM vulnerabilities
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Health plans that try to manage the breakneck pace of change and tsunami of information associated with GBM primarily struggle with three things:
- Policies that cannot keep pace with increasing test volume and complexity
Most health plans’ GBM policies tend to be static and focus on individual tests. While somewhat feasible in the past, this approach is not sustainable. Health plans can’t expect to write a new policy — and maintain it — for every test or panel given the hundreds of thousands of tests on the market. In addition to the growing number of genomics tests available, the scope of the medical specialties impacted by genomics is constantly expanding. Thus, health plans must be prepared to incorporate the latest advances in clinical genomics across their library of medical policies addressing clinical specialties — such as oncology, reproductive health, endocrinology, cardiology, and ophthalmology — to ensure timely coverage of useful treatments and therapies. - Consistency in policy application
The risk of applying genomics policies inconsistently rises when reviewers lack expert-guided resources and references for clinical decision support. For example, a lack of genomics coding expertise may result in apples-to-oranges comparisons of vastly different genomic tests that lead to inappropriate determinations or inaccurate coding. Without providing reviewers with access to continuously updated, evidence-based clinical guidance resources that address genomics across all medical specialties, health plans risk regulatory and compliance issues; inappropriate approvals; inappropriate denials followed by overturns upon appeal; and provider and member abrasion. - Reviewer confidence and job satisfaction. The ongoing tsunami of genomics information makes it hard for clinical reviewers to keep up with the latest science and best practices all on their own. Therefore, a lack of clear, relevant and up-to-date policy guidance for clinical reviewers enabling accurate and consistent decisions may require reviewers to spend a lot of additional time evaluating each request. This may cause them to feel overwhelmed, as well as drive up review costs and resource utilization. Ultimately, even with extra time and effort, inconsistent and incorrect policy applications and therefore, inappropriate determinations, may still occur.
Pursue the GBM program ideal
Above all, health plans want to be confident that their GBM program gives members access to the most clinically useful genomics tests at the right time to drive effective care and improved health outcomes. Few would argue with the statement that solid GBM starts with strong genomics policies and coverage criteria.
Clear, clinically-relevant genomic testing policies written by clinical genomics experts can help ensure that genomic testing coverage guidelines are evidence-based, up-to-date, and easy to use. When coupled with step-by-step workflows and decision aids, health plans can enable consistent and reliable genomic policy application across multiple clinical reviewers.
Moreover, policies that guide appropriate clinical decision-making when step-by-step testing cascades are involved – such as with reproductive testing or tumor testing – allow health plans to engage providers collegially, utilizing these policies as a roadmap to assist providers looking for the most appropriate testing pathway for a given clinical situation. This not only guides members towards the right test at the right time, but limits inappropriate testing and related downstream procedures that can add costs and risks for members. Such support goes a long way toward making providers and members feel they are being heard and well cared for. Indeed, clinicians appreciate when real-world clinical expertise is behind real-world guidance.
What to consider when evaluating avenues to access GBM expertise
Health plans seeking expert clinical genomics guidance should evaluate resources across three domains: quality of clinical guidance, clinically appropriate cost management, and clinical reviewer support. Here are a few things to consider within each domain:
- Quality of clinical guidance
First, what are the professional genomics credentials of the individuals providing the expert guidance? Then, be sure those credentialed individuals are the ones directly involved in writing the genomic policy criteria. Also, be certain the expert resource you choose ensures that their policy criteria is reviewed through a sound external review process. Look for guidance that allows your health plan to create a dynamic, flexible genomics policy framework capable of accommodating fast-paced change without extensive policy revisions. At a minimum, expect quarterly evidence updates so policy keeps pace with rapid changes in genomic testing. - Clinically appropriate cost management
Check that the scope of the organization’s GBM program encompasses expert guidance in crucial clinical categories that genomics touches, such as cancer, reproductive health, rare disease, and pharmacogenomics. Also, verify that relevant clinical practice considerations are factored into the cost management strategy so that clinical quality and value remain high while appropriately reducing clinically unnecessary costs. - Clinical reviewer support. Ask how your health plan’s internal review teams can readily access expert guidance when they need it to support informed decision-making and facilitate effective peer-to-peer conversations. This includes up-to-date genomics policy criteria, ready-to-apply clinical decision aids and decision trees, access to relevant references and clinical evidence library, and coding guidance for accurate test identification.
Finally, check provider and member satisfaction rates for the expert guidance program. Satisfaction rates and real-world examples should be readily available for any expert resource your health plan is considering.
Fortifying policies and relationships with genomics expertise
GBM is increasingly crucial but involves significant nuances and complexities that few health plans have the in-house expertise to manage effectively on their own. Engaging experienced and supportive genomics specialists enables health plans to fortify their GBM programs.
By delivering clinical guidance and expertise aligned with current clinical best practices, genomics specialists can help health plans ensure their members have access to the right genomics tests at the right time to drive improved health outcomes and value. With expertise generating confidence in the health plan’s genomics policies, provider and member relationships will be strengthened.
Photo: iLexx, Getty Images
Kelly Athman is a board-certified genetic counselor with more than 15 years of experience in the healthcare industry. Her passion about increasing access to genomics care and appropriate testing drives her role as the senior director of medical affairs at InformedDNA. Having worked within a health plan prior to pursuing a career in genomics enables Kelly to bring a unique perspective on the intersection of genomics and benefits management. Prior to joining InformedDNA, she served as a genetic counselor for Fairview Hospitals and Clinics, Children’s Mercy Hospital, and CentraCare Health Systems. Kelly holds an M.S. in Molecular, Cellular, Developmental Biology & Genetics and a B.A. in Psychology and Biology from the University of Minnesota.
