Coupling Genetic Counseling to Test Coverage

By Michael Young

As debates surrounding genetic patent rights begin to settle, new questions and disputes have started to emerge around insurance coverage for genetic testing.  For the first time, a U.S. health insurance provider (Cigna) has decided to require evaluation by an American Board of Medical Genetics or American Board of Genetic Counseling certified counselor before covering the costs of genetic testing, including genetic tests for susceptibility to breast and ovarian cancer (e.g., BRCA1 and BRCA2).  Cigna specifies in its new coverage policy statement, which goes into effect on September 15, 2013, that coverage for such testing will require recommendation by a certified genetic counselor based on pre-test individual evaluation, pedigree analysis, and intent to engage in post-test counseling.

By mandating genetic counseling prior to testing, this requirement aims to reduce unnecessary tests and to increase the efficiency and efficacy of health risk management and service delivery. Earlier this week, however, the American Society of Clinical Oncology (ASCO) took aim at Cigna’s policy, claiming that it can “negatively impact the care of cancer patients by serving as a barrier to the appropriate use of genetic testing services.”  At least four key considerations appear to underpin ASCO’s apprehensions about Cigna’s new policy.

First, ASCO is concerned that Cigna’s policy “inappropriately limits oncology health care providers’ ability to deliver services to patients,” and overlooks the qualifications of oncologists to independently determine the appropriateness of genetic testing.  Second, ASCO maintains that the policy threatens the autonomy of patients and providers, stating that “it should be up to the care team and the patient to decide who should deliver the information” and that the policy “eliminates patients’ choice in obtaining information from the provider they wish.”  Third, it challenges the empirical assumption that requiring genetic counseling will reduce unnecessary testing; to the contrary, ASCO contends that “the policy is likely to increase costs by requiring unnecessary outside referral for services that could normally be provided within the regular scope of oncology practice.”  Finally, ASCO proffers that the policy can be detrimental to the health of some patients, anticipating that it might “result in patients opting out of genetic testing, even when testing is beneficial, because of the need for an additional referral.”

Will wedding coverage to counseling indeed cut costs and improve efficiency?  As ongoing monitoring sheds light on this empirical question, how will the normative issues at stake in this debate influence the propriety of insurer-mandated genetic counseling prior to testing?