CEO SUMMARY: Obstetricians and gynecologists have told health insurers that requiring genetic counseling before approval of genetic testing has a negative effect on patient care and is unnecessary. Recently, two ob-gyn associations went on record opposing such requirements. Ob-gyns say they are trained and capable to recognize which patients need such testing. Clinical labs offering genetic testing have an opportunity to serve ob-gyns by assisting them in getting approval for these genetic tests.
INTERESTING BATTLE LINES ARE BEING FORMED between physicians who order genetic tests and health insurers that require genetic testing before these tests can be ordered.
Just seven months ago, the American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists joined those battle lines. The two national medical associations complained that health insurers’ efforts to restrict access to genetic testing have a negative effect on patient care.
These physicians point out that more insurers now stipulate burdensome prior authorization for physicians seeking to order genetic tests. One of the requirements is that only genetic counselors can provide such counseling to patients.
“ACOG opposes such attempts to restrict the scope of practice of obstetrician-gynecologists, who are fully qualified to provide pre-test counseling to their patients,” the ob-gyn organizations said in a statement issued in December 2015. “Board-certified ob-gyns are skilled, dedicated healthcare professionals with more-than-sufficient training to order genetic testing and to counsel patients prior to and after testing. In many cases, a woman’s trusted ob-gyn is the ideal and preferred messenger of health information.”
In some areas of the country where there are fewer genetic counselors, requiring women to get genetic counseling only from genetic counselors will hurt patients particularly hard, ACOG said.
Since the statements were issued, insurers have done nothing to change their requirements, stated Mark DeFrancesco, MD, an ob-gyn in Waterbury, Conn., and ACOG’s immediate past president.
an opportunity for Labs
This issue is important for clinical laboratories because, as DeFrancesco explained, some labs work closely with physicians to ensure that insurers approve physicians’ requests for such testing.
“Some insurance companies do not require genetic counseling, but many do have such requirements and almost all insurers require preauthorization,” he said. “That’s where it’s important for us as physicians to work closely with labs that do this testing.
“One example of this collaboration involves a major lab,” noted DeFrancesco. “It asks me to fill out the paperwork, indicate the family history and the other demographic data and send that information with the specimen to the lab. Then, the lab runs interference for me with the insurance company.
Labs, physicians Collaborate
“The lab will call the insurance company, present the case to them, and generally get authorization,” he stated. “I don’t have an exact count, but it’s been very rare that any insurer has turned down one of my patients when I send test requests to this lab.
“That tells you that my selection process for deciding when it is appropriate to order a genetic test must be okay,” added DeFrancesco, “After all, when the insurance companies review the information I submit, they agree with me that the patient meets the criteria. I’m not saying that I’m so special. I’m a typical ob-gyn who knows how to take a family history and knows how to apply that information when genetic testing would be appropriate.
“My point is that when physicians do what they’re trained to do, then usually patients get the testing they should get,” he emphasized. “That raises the question: Why do health insurers put restrictions in place and make it more difficult for patients to get the genetic tests that are appropriate for their care?
“As physicians, we order these tests based on whether a patient meets certain criteria,” he explained. “Regardless of their specialty, in medical school physicians learn that taking the family history is critical. That’s why it’s one of the first things considered when ordering tests for patients.
“Of course genetic testing is getting more complex,” noted DeFrancesco. “But the fact remains that the family history tells what you need to know about that patient’s risk.
Are there more than ‘x’ number of members of the family who have had breast cancer, ovarian cancer, uterine cancer, pancreatic cancer, or colon cancer?
“There are certain algorithms that physicians have been trained to use to make the fundamental decision of whether the patient reaches a certain level of suspicion and that suspicion is strong enough to qualify for genetic testing,” he added.
“The critical part where a genetic counselor is needed is to interpret results when they are positive,” he explained. “When the genetic test results are negative, the critically important issue to explain to the patient is that—while the tests are negative—that fact does not mean that this patient will never get cancer.
“In simplest terms, it means the patient is not in the high-risk category,” continued DeFrancesco. “That patient remains at a normal risk for cancer. So this doesn’t absolve the physician of going for mammograms in the future. But a genetic counselor is not needed to give patients that message.
“Genetic counselors certainly have a role, especially when a result is positive,” asserted DeFrancesco. “Then the counselor needs to explain the result and discuss what that result means for that individual patient based on the patient’s family and other genetic characteristics.
patient access to Tests
“But for insurers to restrict access to genetic testing unless a genetic counselor is involved does limit access to this testing,” DeFrancesco added. “In fact, many insurance companies allow us to order genetic tests and do the genetic counseling, and some companies have their own genetic counselors, which is fine. But the few health insurers that don’t allow us to do the counseling are delaying care for these patients,” he said.
Contact Mark DeFrancesco, MD, at 203- 574-5501.