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Intermountain Healthcare to Gather Utility Data as SelectHealth Covers PGx Test for Certain Employees


NEW YORK – Intermountain Healthcare next year will begin offering pharmacogenetic testing to a subset of its employees and their beneficiaries as a covered benefit through SelectHealth.

The health insurance company serves more than 900,000 members in Utah and Idaho. As a subsidiary of the Salt Lake City, Utah-based Intermountain Healthcare, SelectHealth also provides health insurance to the healthcare system's 45,000 employees and their beneficiaries.

Under the arrangement, the insurer has agreed to cover PGx testing for Intermountain employees and family members with major depressive disorder who have failed multiple therapies. According to Jason Gillman, director of precision genomics at Intermountain, SelectHealth will cover about 30 ICD-10 codes related to major depressive disorder but he did not specify the exact PGx variants that will be tested within the program.

In turn, Intermountain will collect evidence on how testing is impacting patients' outcomes, which will inform its decision to continue the benefit for its employees, and maybe even influence SelectHealth's decision to cover PGx testing for other members.

At the annual Personalized Medicine Conference in Boston last week, SelectHealth Medical Director Roy Gandolfi noted in a presentation that payors have resisted reimbursing PGx testing for patients due to the lack of clinical utility evidence.

"Unfortunately, [while] the data we see on [pharmacogenomics testing] has been promising, when we look at efficacy or side effects, emergency room visits, hospitalizations, and cost effectiveness, sometimes the payors will look at this and go, 'We don't think there is still value,'" Gandolfi said. He added that SelectHealth has agreed to cover PGx testing within Intermountain's self-insured plan for those who have depression and meet specific criteria in the hopes of gathering that clinical utility evidence.

Gillman said that Intermountain began discussions regarding the coverage arrangement with SelectHealth a few months ago. The covered benefit will start Jan. 1, 2020.

While the collaborators are still solidifying the specific outcomes they will track and the clinical utility evidence they will collect, Gillman said that the team is interested in things like how quickly PGx-informed treatment with a selective serotonin reuptake inhibitor could help patients achieve remission.

Insurers, meanwhile, are usually concerned with how a covered intervention is impacting their costs. "Now, what we're actually hoping for is that [this] data on PGx is going to give us the clinical outcomes, showing that in a shared risk situation, the value of doing the test was worthwhile for providing better care and [at] less cost," Gandolfi explained.

"We'll monitor that real-world evidence and our team members ... we'll take that back to [Gandalfi] and say, 'Here's what we saw,'" Intermountain Chief of Precision Health and Genomics Lincoln Nadauld added during the talk.

This data will help Intermountain decide whether to continue to offer this benefit under its employee plan. The data may also be useful for other employers who purchase insurance through SelectHealth. "From there, we can go to our employers who buy our insurance, [and say] we now have demonstrated that this initial cost, which then may increase your premium, is going to be worthwhile in the long run," Gandolfi said.

In an email, Gandolfi elaborated further that with the addition of medical services, such as pharmacogenomics, self-insured plans, and potentially members, may incur additional costs. Typically, the employer would shoulder between 60 percent and 70 percent of the increase in cost of the premium, and pass on between 30 percent and 40 percent of the cost to the member.

"In this case, with pharmacogenomics offered by Intermountain's self-insured plan, the increase in cost of [providing] the test may be offset by fewer hospitalizations for adverse drug reactions or fewer emergency room visits due to compliance by the member who is taking the medication," Gandolfi explained. 

Although Gandolfi discussed the arrangement between SelectHealth and Intermountain in terms of sharing risk, Gillman clarified the term is a bit of a misnomer, as "that would indicate we're bearing some of the [cost burden]." He explained that the project would be a covered benefit, but Intermountain wouldn't be on the hook to pay SelectHealth any money back should there be greater costs associated with it.

"Because we're sister corporations ... we'll have it as a covered benefit, monitor it, and see how it's progressing," Gillman said. "If it's a positive outcome, we'll keep it as a benefit, and if it's negative, we'll end it as a benefit. Patients can still elect in with their physicians, but it might not be covered by insurance."

If successful, the team may expand the PGx benefit into other settings, such as malignant hypothermia, cardiovascular disease, or in-surgery patients.

At the meeting, several employers said they were offering or planned to offer PGx testing as part of employee benefits programs. These programs come at a time when the US Food and Drug Administration has stepped up scrutiny of labs offering PGx testing. As a result, some labs have stopped reporting drugs linked to PGx variants in test reports and have decided instead to communicate patients' drug response information to doctors through pharmacists. 

Gillman assured that Intermountain would provide testing in a way as not to raise regulatory concerns. "Everything is in scope of normal medical practice since we're pharmacist-driven," he explained.