UCSF

Evidence and Reimbursement For Personalized Medicine Program

A major focus of our work is healthcare coverage and reimbursement policy decisions by payers. Since 2007, TRANSPERS has convened an Evidence and Reimbursement Payer Advisory Council comprised of private payers and thought leaders. This unique advisory group includes senior executives from the eight largest commercial US health plans and leading regional plans as well as thought leaders from research, policy and government.

Our work addresses two critical gaps in the translation of personalized medicine into healthcare practice and policy:

  • The need for an evidence base on personalized medicine to enable policy decisions.
  • The need for a forum that brings together the necessary stakeholders to formulate, recommend, and implement relevant policies and approaches.

An evidence-based approach

Through our collaborative efforts, we address a range of important challenges using evidence-based approaches. These include:

  • Identify gaps in the personalized medicine evidence base and how to address them
  • Analyze how payers make policy decisions and the implications for patients, providers health systems and researchers
  • Examine how personalized medicine is affected by the Affordable Health Care Act and how it is integrated into new healthcare models
  • Develop approaches to work with payers that seek to harness data on the use of personalized medicine
  • Create and test, together with payers, a framework for evaluating healthcare system factors for policy decisions
  • Assess the development and timing of payer policies on key examples of personalized medicine, including genomic sequencing
  • Generate a predictive model of the factors that lead to the successful adoption of new technologies in healthcare

TRANSPERS Program on Evidence and Reimbursement of Personalized Medicine

Conceptual framework – Stakeholders, Topics, Capabilities

Payer Approach Diagram

The Payer Advisory Council is funded primarily by the National Institutes of Health, with additional funding from foundations.

Payer Board Council Photo

Participating health plans include Aetna, Anthem, Cambia Health Solutions / Regence, CIGNA, Health Care Service Corporation, Health Net, Highmark, Humana, Kaiser Permanente, Premera Blue Cross, UnitedHealth Group, and Beacon Laboratory Benefit Management Solutions.

A summary of the Payer Advisory Council is available PDF iconhere.

Accomplishments

Our work with the Council has influenced the conversation about payer coverage issues through approximately 30 peer-reviewed publications and presentations to a range of organizations.

 

  1. Trosman JR, Douglas MP, Liang S, Weldon CB, Kurian AW, Kelley RK, Phillips KA. Insights from a Temporal Assessment of Increases in U.S. Private Payer Coverage of Tumor Sequencing from 2015 to 2019. Value Health. Pending Publication
  2. Trosman JR, Weldon CB, Slavotinek A, Norton ME, Douglas MP, Phillips KA. Perspectives of US private payers on insurance coverage for pediatric and prenatal exome sequencing: Results of a study from the Program in Prenatal and Pediatric Genomic Sequencing (P3EGS). Genet Med. 2019 Sep 10. [Epub ahead of print]
  3. Phillips KA, Deverka PA. The Emerging Use By Commercial Payers Of Third-Party Lab Benefit Managers For Genetic Testing. Health Affairs Blog. 2019. https://www.healthaffairs.org/do/10.1377/hblog20191021.563154/full/
  4. Douglas MP, Parker SL, Trosman JR, Slavotinek AM, Phillips KA. Private Payer Coverage Policies for Exome Sequencing (ES) in Pediatric Patients: Trends Over Time and Analysis of Evidence Cited. Genet Med. 2019;21(1):152-160.
  5. Phillips KA, Trosman JR, Deverka PA, Quinn B, Tunis S, Neumann PJ, Chambers JD, Garrison LP, Douglas MP, Weldon CB. Insurance Coverage for Genomic Tests. Science. 2018;360(6386):278-279.
  6. Phillips KA, Deverka PA, Douglas MP, Hooker G. Genetic Test Availability and Spending. Where Are We Now? Where Are We Going? Health Affairs. 2018;37(5):710-716.
  7. Trosman JR, Weldon CB, Gradishar WJ, Benson AB, Cristofanilli M, Kurian AW, Ford JM, Balch A, Watkins J, Phillips KA. Measuring the Value of Multigene Clinical Sequencing: Evolution of Payer Frameworks and a Path Forward. Value Health. 2018; 21(9):1062-1068.
  8. Phillips KA. Evolving Payer Coverage Policies on Genomic Sequencing Tests: Beginning of the End or End of the Beginning? JAMA. 2018; Published online April 16, 2018.
  9. Trosman JR, Weldon CB, Douglas MP, Kurian AW, Kelley RK, Deverka PA, Phillips KA. Payer Coverage for Hereditary Cancer Panels: Barriers, Opportunities, and Implications for the Precision Medicine Initiative. J Natl Compr Canc Netw. 2017;15(2):219-228.
  10. Phillips KA, Deverka PA, Trosman JR, Douglas MP, Chambers JD, Weldon CB, Dervan AP. Payer Coverage Policies for Multigene Tests. Nature Biotechnol. 2017;35(7):614-617.
  11. Dervan AP, Deverka PA, Trosman JR, Weldon CB, Douglas MP, Phillips KA. Payer decision making for next-generation sequencing-based genetic tests: insights from cell-free DNA prenatal screening. Genet Med. 2017;19(5):559-567.
  12. Clain E, Trosman JR, Douglas MP, Weldon CB, Phillips KA. Emergence of New BRCA1/2 Tests and Gene Panels: Availability & Payer Coverage Policies. Nature Biotechnology. 2015;33(9):900-2.
  13. Trosman JT, Weldon CB, Kelley RK, Phillips KA. Challenges of coverage policy development for next-generation tumor sequencing panels: experts and payers weigh in. J Natl Compr Canc Netw. 2015 Mar;13(3):311-8.
  14. Schink JC, Trosman JR, Weldon CB, Kalliopi P. Siziopikou, Gregory J. Tsongalis, Alfred W. Rademaker, Jyoti D. Patel, Al B. Benson III, Edith A. Perez, William J. Gradishar. Biomarker Testing for Breast, Lung, and Gastroesophageal Cancers at NCI Designated Cancer Centers. J Natl Cancer Inst (2014) 106(10): dju256
  15. Phillips KA, Trosman JR, et al. Genomic Sequencing: Assessing The Health Care System, Policy, And Big-Data Implications. Health Affairs.2014;33(7):1246-1253.
  16. Phillips KA, Ann Sakowski J, Trosman J, Douglas MP, Liang SY, Neumann P. The economic value of personalized medicine tests: what we know and what we need to know. Genet Med. 2013;16(3):251-257.
  17. Trosman JR, Weldon CB, Schink JC, Gradishar WJ, and Benson AB. What do providers, payers and patients need from comparative effectiveness research on diagnostics? The case of HER2/Neu testing in breast cancer. Journal of Comparative Effectiveness Research 2013;2(4):461-477.
  18. Weldon CB, Trosman JR, Gradishar WJ, Benson AB, Schink JC. Barriers to the Use of Personalized Medicine in Breast Cancer. Journal of Oncology Practice. 2012;8(4):24e-31e.
  19. Wang G, Beattie M, Ponce NA, Phillips KA. Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling. Genet Med. 2011;13(12):1045-50.
  20. Haas JS, Liang SY, Hassett MJ, Shiboski S, Elkin EB, Phillips KA. Gene expression profile testing for breast cancer and the use of chemotherapy, serious adverse effects, and costs of care. Breast Cancer Res Treat. 2011;130(2):619-26.
  21. Haas JS, Phillips KA, Liang SY, Hassett MJ, Keohane C, Elkin EB, Armstrong J, Toscano, M. Genomic Testing and Therapies for Breast Cancer in Clinical Practice. Journal of Oncology Practice. 2011;7(3S):e1s-e7s.
  22. Liang SY, Phillips KA, Wang G, Keohane C, Armstrong J, Morris WM, Haas JS. Tradeoffs of using administrative claims and medical records to identify the use of personalized medicine for patients with breast cancer. Medical Care. 2011;49(6):e1-8.
  23. Trosman JR, Van Bebber SL, Phillips KA. Health Technology Assessment and Private Payers’ Coverage of Personalized Medicine. American Journal of Managed Care. 2011;17(5 Spec No.):SP53-SP60.
  24. Kelley RK, Van Bebber SL, Phillips KA, Venook AP. Personalized medicine and oncology practice guidelines: a case study of contemporary biomarkers in colorectal cancer. Journal of the National Comprehensive Cancer Network. 2011;9(1):13-25.
  25. Trosman JR, Van Bebber SL, Phillips KA. Coverage Policy Development for Personalized Medicine: Private Payer Perspective on Developing Policy for the 21-Gene Assay. Journal of Oncology Practice. 2010;6(5): 238-242.
  26. Van Bebber SL, Trosman JR, Liang SY, Wang G, Marshall DA, Knight S & Phillips KA. Capacity building for assessing new technologies: approaches to examining personalized medicine in practice. Personalized Medicine 2010;7(4): 427–439.
  27. Phillips KA, Marshall DA, Haas JS, Elkin EB, Liang SY, Hassett MJ, Ferrusi I, Brock JE, Van Bebber SL. Clinical Practice Patterns and Cost Effectiveness of Human Epidermal Growth Receptor 2 Testing Strategies in Breast Cancer Patients. Cancer. 2009;115(22):5166-74.
  28. Phillips KA, Liang S, Van Bebber S, CANPERS Research Group. Challenges to the translation of genomic information into clinical practice and health policy: Utilization, preferences and economic value. Curr Opin Mol Ther. 2008;10(3):260-6.
  29. Phillips KA. Closing the Evidence Gap in the Use of Emerging Testing Technologies in Clinical Practice. JAMA. 2008;300(21):2542-4.