dna, genomics

DNA, genomics

It’s easy for health plans to think of 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 few regulations, genomics must be approached differently when developing clinical policy and implementing utilization management strategies.

That’s why:

Now there are more than 167,000 genomic tests on the market. Yet there are only just over 400 CPT codes to represent them. This makes ensuring accurate coding and test comparisons against policy and between laboratories complex and nuanced.

Furthermore, many genomic tests are released for commercial use before there is clinical evidence demonstrating their clinical utility or comparing them to currently available diagnostic, treatment, or management options. Consequently, health plans often must develop coverage criteria for genomic testing using much less robust clinical evidence than they typically have to develop policies in other medical specialties.

Because of all these complexities, health plans’ genomic benefit management (GBM) programs face significant vulnerabilities. Without the help of genomics professionals, it is difficult 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 support to manage utilization.

Understand current GBM vulnerabilities

Health plans trying to manage the breakneck speed of change and the tsunami of information related to GBM are primarily struggling with three things:

  • Policies that cannot keep up with the increasing volume and complexity of tests
    Most health plans’ GBM policies tend to be static and focus on individual tests. Although somewhat feasible in the past, this approach is not sustainable. Health plans cannot 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 genomic tests available, scope of medical specialties influenced by genomics is constantly expanding. Thus, health plans must be prepared to incorporate the latest advances in clinical genomics into their library of medical policies targeting clinical specialties—such as oncology, reproductive health, endocrinology, cardiology, and ophthalmology—to ensure timely coverage of beneficial treatments. and therapies.
  • Consistency in policy implementation
    The risk of inconsistent application of genomic policies increases when reviewers lack expert-led resources and references to support clinical decisions. For example, lack of expertise in genomic coding can lead to 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 guideline resources that address genomics across medical specialties, health plans risk regulatory and compliance issues; inappropriate endorsements; improper denials followed by reversal on appeal; and supplier and member abrasion.
  • Reviewer confidence and job satisfaction. The ongoing tsunami of genomic information makes it difficult for clinical reviewers to keep up with the latest scientific advances and best practices on their own. Therefore, the lack of clear, relevant and up-to-date policy guidelines for clinical reviewers allowing for accurate and consistent decisions may require reviewers to spend a lot of extra time evaluating each request. This can make them feel overwhelmed as well as increase review costs and resource usage. Ultimately, even with additional time and effort, inconsistent and incorrect policy applications and therefore inappropriate decisions can still occur.

Pursue the ideal GBM program

Above all, health plans want to be confident that their GBM program is giving members access to the most useful clinical genomic tests at the right time to drive effective care and improved health outcomes. Few would argue that solid GBM starts with strong genomic policies and coverage criteria.

Clear, clinically relevant genomic testing policies written by experts in clinical genomics can help ensure that genomic testing coverage guidelines are evidence-based, up-to-date, and easy to use. When combined with step-by-step workflows and decision aids, health plans can enable consistent and reliable application of genomic policy across multiple clinical reviewers.

Additionally, policies that guide appropriate clinical decision-making when step-by-step testing cascades are involved—such as with reproductive or tumor testing—allow health plans to engage providers collegially, using these policies as a roadmap to support to providers seeking the most appropriate research pathway for a given clinical situation. This not only directs members to the right test at the right time, but limits inappropriate tests and associated downstream procedures that can add costs and risks to members. Such support goes a long way in helping providers and members feel heard and well cared for. Indeed, clinicians appreciate when real-world clinical experience is behind real-world guidelines.

What to consider when evaluating pathways to access GBM expertise

Health plans seeking expert clinical genomics guidance should evaluate resources in three areas: quality of clinical guidance, clinically appropriate cost management, and clinical reviewer support. Here are a few things to keep in mind with any domain:

  • Quality of clinical leadership
    First, what are the professional genomic credentials of the individuals providing the expert guidance? Then ensure that these accredited individuals are the ones directly involved in writing the genome policy criteria. Also, ensure that your chosen expert resource ensures that their policy criteria are reviewed through a robust external review process. Look for guidance that allows your health plan to create a dynamic, flexible genomics policy framework capable of accommodating rapid changes without extensive policy revisions. Expect at least quarterly evidence updates so policy can keep pace with rapid changes in genomic testing.
  • Clinically appropriate cost management
    Verify that the organization’s GBM program scope includes expert guidance in key clinical categories that affect genomics, such as cancer, reproductive health, rare diseases, and pharmacogenomics. Also check that relevant clinical practice considerations are incorporated 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 easily access expert guidance when they need it to support informed decision-making and facilitate effective conversations between partners. This includes up-to-date genomic policy criteria, ready-to-use clinical decision aids and decision trees, access to relevant references and a library of clinical evidence, and coding guidelines for accurate test identification.

Finally, check the satisfaction rate of the providers and members of the expert referral program. Satisfaction levels and real-world examples should be readily available to any expert resource your health plan is considering.

Strengthening policies and relationships with genomics expertise

GBM is increasingly key, but involves significant nuances and complexities that few health plans have the in-house expertise to manage effectively on their own. Hiring experienced and supportive genomics professionals allows health plans to strengthen their GBM programs.

By providing clinical guidance and expertise aligned with current clinical best practices, genomics professionals can help health plans ensure that their members have access to the right genomic tests at the right time to drive improved health outcomes and value. With expertise generating trust in health plan genomic policies, provider-member relationships will be strengthened.

Photo: iLexx, Getty Images

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