CEO SUMMARY: Cigna was the first national health insurer to require independent board-certified genetic counseling before approving coverage for certain genetic tests. Since launching this program in September 2013, the insurer has seen a 450% increase in genetic counseling for Cigna members. Such counseling has helped to reduce utilization of genetic testing because informed patients understand that a genetic test might not be appropriate for them.
WITH MORE GENETIC COUNSELING comes reduced levels of genetic testing, according to Cigna, a national health insurance company in Bloomfield, Connecticut.
In September 2013, Cigna became the first national health insurer to require genetic counseling before approving coverage for some genetic tests. The company required counseling from an independent board-certified genetics specialist for any member seeking coverage for certain genetic testing and who was at heightened risk for certain hereditary conditions, such as breast cancer, colorectal cancer, or long QT syndrome. (See TDR, August 19, 2013.)
“Since implementing the program, the number of members getting counseling from a board-certified genetics specialist has increased 4.5 times,” stated David Finley, M.D., Cigna’s National Medical Officer for Enterprise Affordability and Policy. “Such counseling has also helped to reduce genetic testing because more-informed patients saw that genetic testing is appropriate only for a subset of patients and conditions.”
The reduction in genetic testing is a significant result even though the counseling was not designed to reduce testing, noted Finley. “Since 2012, we have seen an 88% increase in requests for genetic tests each year,” he said. “That’s an enormous increase in costs per year and it is not a stable situation.” Cigna has also seen sharp increases in drug testing, he added.
Reduced Genetic Testing
“After seeing the results of its genetic counseling program, Cigna is evaluating whether to expand this program to other types of genetic tests—in part because it has helped to reduce genetic testing and because members are making better, more informed choices about potentially life-altering medical decisions,” said Finley.
Empowering patients was the primary goal when Cigna implemented the genetic counseling program in 2013. “We saw this as a way to ensure that Cigna members got the proper genetic tests at the right time,” explained Finley. “It was equally important to ensure that members understood what genetic testing would reveal about their health.”
One outcome from genetic counseling was that a higher percentage of Cigna members who were considering getting genetic tests chose not to get tested. “Once these members learned about the genetic test, they found either they didn’t want it or they didn’t meet the criteria,” Finley said. “We also saw members who met the criteria but didn’t want the genetic test because it was not going to change anything for them, whether it was for treatment or follow up.
“One major outcome from genetic counseling is that Cigna members can make fact-based decisions rather than decisions based on incorrect information and assumptions,” he continued. “That was the focus of the genetic counseling program and it is working well.
“There is so much misunderstanding and misinformation about genetic testing, particularly about who should be tested and what the test results mean,” he added.
In its evaluation of genetic counseling, Cigna has been assessing its return on investment. “Yes, there may be a return that would save money and cover the cost of genetic counseling,” he said. “That leads to the question of whether Cigna will expand the genetic counseling requirement to other tests. That’s something we’re considering even though the reason Cigna adopted this policy was not financial.
“If the cost of genetic counseling is compared to the cost of a test not being done—in the short term, the money savings are just about break-even,” stated Finley. “Long term, we don’t know if we’ll see significant financial benefits.
“Take the example of a woman who has a BRCA test and the result shows a variation of unknown significance,” Finley stated. “Assume, after genetic counseling, that the woman elects not to have surgery.
“In this case, that woman will be followed closely and have a series of MRIs over the next several years because MRIs are a sensitive way of picking up early changes in the breast,” he continued. “But MRIs done every year over the many years cost tens of thousands of dollars.
“This woman also could have a double mastectomy, and that costs thousands of dollars,” observed Finley. “Therefore, if Cigna can ensure that the genetic tests done for the patient are the ones that need to be done, then it may be able to reduce the downstream costs while helping patients get the best outcomes.”
Cigna’s focus on genetic and molecular testing is significant because all insurers are spending more as test utilization has risen. Before last year, Cigna and other insurers struggled to manage the cost of these tests but coding changes implemented last year have helped Cigna make better decisions about which tests to cover, Finley said.
“Prior to 2013, all the codes for these tests were unspecific,” he noted. “Therefore, we had no way to know the purpose of each genetic or molecular test. The test request would say it was for DNA extraction, or DNA amplification, or DNA sequencing. Those descriptions told us nothing.
Confusion over Coding
“It could be any type of molecular or genetic test—yet labs would use the same codes,” he stated. “We could not identify the specific test that was being done for the patient and so we were unable to manage what was being done. All we could do was pay the claims.
“Now, the molecular and genetic test codes are more specific, allowing us to identify the tests as the orders come in and we put them into one of three categories: Tests we pay for, tests we never pay for, and the tests that require more information on whether or not the patient meets criteria,” Finley said.
“This change in lab test coding occurred at the same that we saw the 88% increase in test utilization,” he added. “So the extent to which the change came as a result of the new coding or increased utilization is hard to tell. My belief is that a large part of this is due to increased utilization.
“The change in genetic test coding was done in conjunction with what Medicare was doing with genetic and molecular testing and with what the AMA did to improve CPT coding,” Finley explained.
“For Cigna, the problem was how to handle the thousands of genetic tests that exist and develop reimbursement guidelines for each test,” he observed. “The AMA came up with 10 tiers for the different tests. Tier one codes would be the most common tests and that left thousands of other tests to be grouped into nine other tiers.
“It’s still a challenge because each tier has hundreds or thousands of tests, but at least we now have a system for the most common tests,” stated Finley. “It’s not completely under control because of the nonspecific nature of the codes beyond tier one.
More Precision Analysis
“When Cigna evaluates a molecular or genetic test for payment, it looks at whether the test is effective and whether it improves patient outcomes,” he added. “Because we can’t manage everything, this approach helps us choose which tests make the most sense for our customers.
“To prioritize this process, we put genetic tests into categories,” said Finley. “Common tests go in one category and the commonly misunderstood tests make up another category.
“A third category has the very expensive tests,” he noted. “We manage the tests that are misunderstood and the ones that are expensive. Thus, we pay for certain tests that meet medical criteria and we do not pay for tests that do not meet medical criteria.
“Of course, there remain many genetic tests that we have not evaluated under this system,” stated Finley. “If Cigna has no comment on these tests, it means they are payable.
“We also do the best we can to focus on the tests we can manage,” concluded Finley. “We have a genetic counseling company, InformedDNA, that advises us. It helps us determine which genetic tests are likely to be beneficial in terms of improving patient outcomes.”
Last Summer’s ‘Angelina Jolie’ Effect Increased Demand for Genetic Breast Cancer Tests, Cigna Says
IN MAY 2013, WHEN ANGELINA JOLIE REVEALED her double mastectomy, many other woman who were similarly at risk for breast cancer decided to have the same surgery. Jolie opted for the procedure after learning she has the BRCA1 gene and thus had an increased risk of breast cancer.
“Since that news came out, we saw an increase of 60% to 70% in requests from patients for the BRCA1 and BRCA2 tests, and that has continued,” stated David Finley, M.D., Cigna’s National Medical Officer for Enterprise Affordability and Policy. “That surprised us.
“In our counseling program for genetic testing, about 80% to 90% of the test requests are for the BRCA tests,” he explained.
“At the same, we have also seen a rise in the use of genetic counseling and that our members want this counseling,” he noted. “Of course, more genetic tests are being introduced all the time and that leads to more counseling.
“Each laboratory company developing genetic tests believes in its product,” he said. “But Cigna must assess each new genetic test to see if it may be the right thing to do medically or not. We want to know if a test will change the patient’s clinical outcome. When this standard is applied, there is a decrease in the number of genetic tests that are ordered.
“Genetic counselors are trained to address that question: will this test affect the patient’s clinical outcome,” Finley explained. “That’s one reason genetic counseling is good for patients. However, the patient benefits in another way from this counseling because it helps decrease the number of diagnostic odysseys and fishing expeditions that some patients experience when treating physicians are unsure about a diagnosis.
“Genetic counselors know that, as individuals have genetic testing done, there will be mutations and variations of unknown significance,” he said. “That’s a problem because that leads to more testing and that testing is not free. There is the dollar cost of the test, but there is also the cost in terms of the increased anxiety for the patient. Genetic counselors can help prevent both of these unnecessary costs.
“When it comes to cancer, for example, there are many misunderstandings about what genetic testing can do,” continued Finley. “Many women believe that—just because they have a certain gene— they are at risk for breast cancer. Others believe that, if they don’t have this gene, then they don’t have to worry about breast cancer. This is dangerous thinking in both cases.
Benefits of Counseling
“The incidence of the BRCA gene in the American population is about 2% and the chance of a woman getting breast cancer in America is about 1 in 8 in her lifetime,” observed Finley. “Genetic counselors help our members understand how such numbers relate to their personal situations. This is one benefit to the genetic counseling program.
“For our counseling, we use board-certified genetic counselors, clinical geneticists, and nurse practitioners with advanced degrees in cancer risk assessment and genetics,” he stated. “We predict the demand for genetic counseling will increase steadily.
“That’s because new genetic tests continue to be introduced,” concluded Finley. “Lately, multigene testing panels have entered the market and physicians don’t have the expertise to answer all the questions patients have about such genetic tests. Referring their patients to genetic counselors is the right way to help the patients evaluate whether or not they would benefit from such genetic tests.”
Health Insurer Sees Jump in Drug Tests, Tox Screens
LIKE MANY HEALTH INSURERS, not only is Cigna handling a larger volume of genetic tests, but it is also seeing big increases in the utilization of drug tests.
“Outside of the significant increase we have seen in genetic testing, we have not seen large increases in clinical lab test utilization, except in one area,” stated David Finley, M.D., Cigna’s National Medical Officer for Enterprise Affordability and Policy. “We have seen large increases in testing for drugs, meaning toxicology screens.
“In the past year, Cigna put in a process to manage that testing,” he continued. “This gives us some guardrails on how much test- ing can be done for substance abuse. “Medicare developed a process for toxicology screens that it uses to reduce some of the abuse for this category of tests. We’ve adopted that approach here at Cigna.
“Specifically, there were CPT codes for toxicology screens for blood or urine that would allow a lab to screen for 30 to 35 toxic substances, and the lab would charge for that screen 35 times,” he explained. “However, this was not the intent of these CPT codes.
“Thus, Medicare said it wouldn’t pay for the same screen done 35 times and now uses a G code or HCPCS code,” noted Finley. “Under the G codes, the lab can still do a toxicology screen for multiple substances. However, Medicare will pay only for a maximum of 10 substances.
“Cigna adopted that same protocol and it has saved a lot of money,” said Finley. “Cigna’s policy is to have labs do a qualitative assay to see what’s there before they do a quantitative assay. This is consistent with Medicare’s policy.”