Genetic counseling relatively low cost, ‘should be offered to more at-risk patients’
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Submitted medical claims and out-of-pocket costs for genetic counseling encounters appeared relatively low among patients with certain cancer types, according to a research letter published in JAMA Health Forum.
Background and methods
Cancer genetics services are becoming increasingly important in the modern delivery of cancer care, Mya L. Roberson, PhD, assistant professor in the department of health policy at Vanderbilt University School of Medicine, told Healio.
“In the policy space, issues related to genetic counseling and genetic testing coverage and access are often collapsed when the policy issues in practice are distinct in meaningful ways,” she said. “For example, certified genetic counselors not being recognized as billable providers by Centers for Medicare & Medicaid Services, which has implications in the commercial insurance space resulting in an unstable reimbursement landscape, with many genetic counseling claims not being submitted at all and instead being absorbed by health care systems.
“In this study of a population of commercially insured adults with cancer for which there are genetic testing recommendations from the National Comprehensive Cancer Network, we sought to characterize costs for cancer genetic counseling encounters for which claims are submitted,” Roberson continued.
Investigators used the IBM Watson Health MarketScan — a nationwide administrative claims database encompassing more than 30 million enrollees in large private insurance plans — to build a cohort of 16,791 patients (92.7% women) with breast (n = 12,722), prostate (n = 356), endometrial (n = 622), ovarian (n = 1,312), colorectal (n = 1,417) or pancreatic cancer (n = 312) who had private insurance and at least one encounter for genetic counseling between 2013 and 2019.
Researchers identified outpatient genetic counseling encounters using Current Procedural Terminology codes 96040 and S0265 among patients with two or more cancer diagnoses codes on two different days within the previous year.
They calculated out-of-pocket costs and total costs — including the sum of coinsurance, copayments and deductibles — paid on claims for genetic counseling encounters and used multivariable adjusted log-binomial regression to calculate adjusted prevalence ratios for patients with out-of-pocket costs for genetic counseling services vs. those without out-of-pocket costs.
Key findings
Results showed a median net payment for genetic counseling encounters of $118 (interquartile range [IQR], $58-$211).
Researchers found that most patients paid nothing for genetic counseling services, with an overall median out-of-pocket cost of $0 (IQR, $0-$16), whereas 31.1% of patients had some out-of-pocket costs.
Of note, compared with patients billed under Current Procedural Terminology code 96040, those billed under code S0265 had a lower prevalence of out-of-pocket costs (adjusted prevalence ratio = 0.52; 95% CI, 0.47-0.59). Moreover, patients with prostate cancer experienced a higher prevalence of out-of-pocket costs for genetic counseling compared with patients with breast cancer (adjusted prevalence ratio = 1.28; 95% CI, 1.04-1.57).
Implications
“When genetic counseling services were covered by insurance, we found that there were little to no out-of-pocket costs for patients. Genetic counseling is something that should be offered to more at-risk patients, so they can make informed decisions about genetic testing and subsequent follow-up care, and to enhance family communication. At present, most genetic testing is done without patients interfacing with a certified genetics health professional,” Roberson told Healio.
“Given the rapidly evolving knowledge about cancer risk management among those with inherited cancer gene mutations, interfacing with genetics professionals in partnership with treating oncologists, surgeons and primary care providers has tremendous potential to enhance quality of care,” Roberson continued. “Policy reform is needed to streamline the financing and reimbursement of genetic counseling services to fully maximize clinical impact. Further research is needed to continue to understand gaps in cancer genetics service delivery and evaluate ways to make service delivery more equitable.”
For more information:
Mya L. Roberson, PhD, can be reached at mya.l.roberson@vumc.org.
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