Cigna announced last week that it will require its members to undergo genetic counseling before deciding to cover genetic testing for heightened risk of breast cancer, colorectal cancer syndromes, or Long QT syndrome.
David Finley, Cigna's chief medical officer of enterprise affordability, told PGx Reporter that these three disease areas are test cases for a broader genetic testing reimbursement policy — a starting point recommended by the genetic counseling service InformedDNA. For Cigna members, InformedDNA will provide online and phone-based genetic counseling services, as well as support the payor in making decisions about when to cover specific tests.
In the future, the program will likely be extended to other types of genetic testing as well, according to Finley.
"We have millions of members, thousands of different groups and different plan documents, and computer systems for claim generation, and now we have to make sure we have a network of genetic counselors available for people to go to," Finley said.
By testing out the genetic counseling program in only three disease settings, Cigna wants to smooth out any kinks in implementation before rolling out the service broadly. "We asked InformedDNA [which tests] would be most valuable to start with, and this is what they [recommended] based on volume, complexity, and medical implications," Finley said.
Under the new policy, Cigna customers interested in testing in one of these three areas will be required to undergo counseling, either by a local genetic counselor in the insurer's network, or through InformedDNA's counseling service over the phone or online. Based on recommendations by the counselor, Cigna will then decide whether or not to cover a subsequent genetic test.
InformedDNA CEO David Nixon said that under new national healthcare reform guidelines, insurers are required to cover genetic counseling fully and without cost sharing for women with family history indicating elevated risk for breast cancer. Cigna will also cover counseling for the other testing areas, he said.
Other insurers, like Aetna and UnitedHealthcare, have adopted policies strongly encouraging genetic counseling and have instituted prior approval strategies under which the payors will cover the cost of the testing only when a person's medical and family history suggests a test is medically necessary according to their own policies and guidelines from professional medical societies. Finley noted, however, that Cigna is the first national carrier to outright require counseling as a way to determine whether genetic testing is medically necessary.
One smaller regional company, Michigan-based Priority Health, also requires genetic counseling according to InformedDNA's Nixon.
The hope with Cigna's new policy, Finley said, is that the approach will allow customers to be more involved in the process, and to have a better understanding of why positive or negative coverage decisions are made.
"Once we decided we needed to manage this, we had a few choices," he explained. "One is standard utilization management where we would have [patients] send their family history, maybe a doctor's note, and we let them know if they meet [the] criteria."
However, that approach doesn't engage the customer in the decision-making process. “They get a letter either saying 'yes' or 'no'. I don’t think that’s really good for genetic testing," he said.
By requiring that people undergo genetic counseling, Cigna is hoping its customers will have a better understanding of whether a genetic test will benefit them, and it will have a way to more accurately determine whether it should pay for genetic testing based on its medical necessity for a particular individual.
"We think both of those ends can be met if we say that we are going to require that [customers] see a genetic counselor,” Finley said. “At the end of the day, they will be educated [and] informed, [and] we will be in a position to make the right coverage decision without upsetting the customer since they've had it explained to them already.”
InformedDNA's Nixon said that the firm is expecting to counsel 100,000 Cigna customers over the next year through this partnership. But Finley predicted that the majority of counseling would still be done by in-person, by local counselors.
"I think most patients will go to genetic counselors in their area," he said. "But there is a problem, in that most [genetic counselors] operate out of a hospital or medical center. They don't go out like dentists or family practice doctors and hang up a shingle in different towns and say, 'Here I am.' It turns out it's just not that kind of practice."
Partnering with InformedDNA will allow the company to make counseling accessible to any and every client who is interested in genetic testing. This will be particularly beneficial to people living in rural areas with limited healthcare access.
"There is a gross shortage of genetic specialists so our phone/online model is the only way to insure broad access to these experts," said Nixon.
"If we didn't insure access [in this way] it wouldn’t work and it wouldn't be fair," Finley added.
Meanwhile, InformedDNA will also work with Cigna behind the scenes in assessing operating labs and tests in the field as the company continues to craft its coverage policy for genetic testing across the board.
"I think it is fair to characterize the genetic testing field as in some chaos right now," Finley said. "Anybody that can buy a sequencing machine can try to invent a test and they are all trying to do IPOs, and do direct-to-consumer advertising."
Furthermore, medical claims codes, called CPT codes, which healthcare providers submit to payors for performed services, don't allow payors to determine which specific tests are being conducted. "We were confronted with claims where we couldn't figure out what test was done because there is very little specificity in the codes, so we decided to start to put together a program to manage genetic testing – to be able to advise groups and customers on which tests have been associated with beneficial outcomes, which are standard of care, which are sometimes useful maybe, and which have never been shown to be useful," Finley said.
While Cigna eventually intends to expand the new counseling requirement beyond breast and colon cancer and Long QT syndrome, Finley did not specify what areas might be next.
He did state, however, that he sees Cigna's move as a significant step beyond other insurers' programs that have recommended, but not required, genetic counseling. While there is no one right way to manage coverage of genetic tests, having first-hand experience with the implementation of recommendation programs by other insurers, Finley believes that coverage programs that don't require genetic counseling have had "very little impact” in decreasing unnecessary testing.