Payer Perspectives of Hereditary Cancer Panels Help Expose Roadblocks to Insurance Coverage


Using recommendations from payers to address hereditary cancer panel (HCP) insurance coverage barriers is critical to ensuring patients’ access to such tests, according to a study published in the Journal of the National Comprehensive Cancer Network (2017;15:219-228).


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HCPs, or tests for multiple genes and syndromes, are the latest advancement in precision medicine and cancer risk assessments. Comprehensive cancer risk assessment is highly pertinent to the Precision Medicine Initiative. However, these tests tend to be controversial and lack formal insurance coverage policy.

Researchers from the UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS) and the UCSF Helen Diller Family Comprehensive Cancer Center conducted a study to identify payers’ perspectives regarding barriers to HCP coverage and opportunities to address them. Researchers conducted interviews with 11 major private payers, which collectively cover over 160 million enrollees in the US. Resulting discussions were framed in the context of Precision Medicine Initiatives priorities.

An overwhelming majority of payers reported that HCP features offer a unique appeal to patients and clinicians. However, numerous barriers to HCP coverage were noted among the responses, including incompatibility with coverage frameworks (100%), lack of necessary evidence (100%), departure from family history-based testing toward genetic screening (91%), lack of rigor in the HCP hybrid research and clinical setting (82%), and patient transparency and involvement concerns (82%).

Additionally, payers shared opportunities to address barriers to HCP coverage. Among the recommendations for addressing barriers were refining HCP-indicated populations (82%), developing evidence of actionability (82%) and pathogenicity (64%), creating infrastructure and standards for informing and recontacting patients (45%), separating research from clinical use in the hybrid research and clinical setting (44%), and adjusting coverage frameworks (18%).

"We hope that our findings bring attention to the topic of insurance coverage for cancer panels and contribute to a productive dialogue among various stakeholders on framing an approach to address payers' concerns," said lead author Julia R Trosman, PhD, Adjunct Assistant Professor, TRANSPERS, in a press release.

An implication of the study are three target areas for the Precision Medicine Initiative design to incorporate payer feedback to strengthen its impact on patients and genetic science: addressing insurance coverage to secure access to future PMI discoveries, incorporating payers' evidentiary requirements into PMI's research agenda, and leveraging payers' recommendations and experience to keep patients informed and involved.