Cigna’s requirement for patient counseling in advance of a specific genetic test being covered demonstrates that the balance of power in the healthcare trilogy is by no means set. While in this case, the payor has directed what it considers to be the appropriate use of genetic testing, Cigna’s action raises these important questions:
- First, are physicians appropriately trained to do counseling?
- Second, do patients know how to deal with probabilities and “relative risks”?
- Third, what should be the role of the payor in medical decisions or treatments?
To me, this move by Cigna highlights an educational need among all players in the trilogy. There is, then, a real role for objective guideline development by a number of concerned groups, taking both individual and societal perspectives.
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Following is more on this topic from my colleagues’ perspectives:
A physician ordering a genetic test should be prepared to understand its results and treatment plan. This sounds simple enough, but according to the U.S. Centers for Disease Control and Prevention, there have been more than 2,200 genetic tests developed and about 2,000 are clinically available. Most of these tests are for rare genetic disorders, but more tests are being developed to determine the risk of common diseases, such as cancer and heart disease. Still more pharmacogenetic tests identify genes that may influence response to medications.
Evidence of clinical utility is still being determined for many of these tests (even the clinically available ones). Meanwhile, patients are learning more about tests and treatment options thanks to the Internet and other sources, and clinicians are trying to keep up with the flood of information and new, patient-generated questions. As the landscape shifts from “ask your doctor about….,” the new consumer question may be “ask your genetic counselor.” This change in question—and Cigna’s decision—point to the fact that most genetic tests require an understanding of the risks associated with the result. A physician could provide this information, but he/she may not be trained nor have the time to analyze treatment options for each patient.
Overall, I think this is a good move for patients on the part of Cigna, even though I’m sure a part of this decision is financially motivated to prevent unnecessary ordering of expensive tests. In my practice as a physician, almost every MRI I order requires pre-authorization and sometimes utilization review or peer review. I think this is just a general trend, because of payor concerns to control costs.
There will be backlash from physicians – as the Bloomberg article mentions – because many physicians feel that they are increasingly restricted in how they practice medicine. Certain specialties are definitely better trained in the nuances of these tests – such as the surgical oncologist quoted in the article and hematologists/oncologists – but the vast majority of physicians probably don’t fully understand these tests and when or how they should be ordered.
A recent City of Hope survey shows that few doctors feel confident enough to order a multi-genome or genome-wide test (even though there are now 20 genes associated with breast cancer), while they are fairly comfortable ordering the BRCA1/BRCA2 tests offered by Myriad. The field of genetic testing is rapidly evolving, and many doctors continue to practice the way they were trained. One would hope in specialties related to oncology, doctors are more well-versed in the current tests, but reimbursement structures may make it difficult for doctors to spend the time with patients to fully explain all of the implications – therefore, genetic counselors can offload some of this burden.