UCSF

Understanding Payer Decision-Making: TRANSPERS Payer Advisory Board

Insurance coverage is critical for sustained implementation of precision medicine into clinical practice. How payers decide on coverage informs research, evidence generation, and clinical adoption of new genomic technologies. This is especially relevant in a multi-payer health care system, such as in the U.S., where inconsistency of decision-making across payers contributes to variable insurance coverage and unequal access to new genomic technologies.

There is a gap in understanding what factors and considerations impact payers’ decision-making, what evidence is needed, and how these factors vary across payers and testing modalities. Additionally, there is a lack of forums to explore payer decision-making objectively. While companies engage payers in advisory boards, these boards tend to serve commercial interests rather than independent research.

To address this, we assembled the UCSF TRANSPERS Payer Advisory Board in 2007. Since then, we have conducted a unique research program in collaboration with the board.

Board members represent key stakeholders, including:

  • Leading national and regional private insurer plans
  • Business groups representing large, self-insured employers
  • Laboratory benefit management companies
  • Experts in public payer policies

Our research program is conducted using two methods:

  • Individual interview studies with Board members on their perspectives relevant to coverage decision-making for emerging technologies and tests
  • Board roundtables featuring group discussions

Since the founding of the Board, our research has resulted in numerous peer-reviewed publications in major journals, as well as reports. Our work has been widely cited and used by researchers, payers, industry, organizations, and venture capital firms. Our 2020 paper in Genetics in Medicine on perspectives of U.S. private payers on insurance coverage for pediatric and prenatal exome sequencing was among their top 15% articles cited that year.

Payer Board Council Photo

Participating health plans have included 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.

PDF iconPrintable Summary: Payer Advisory Board (PDF)

Accomplishments

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

  1. Douglas MP, Gray SW, Phillips KA. Private Payer and Medicare Coverage Policies for Circulating Tumor DNA Testing in Cancer Patients: Trends from 2015-2019. J Natl Compr Canc Netw. 2020;18(7):866-872.

  2. 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. 2020;23(5):551-558.

  3. 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. 2020;22(2): 283-291.

  4. 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/

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. Phillips KA. Evolving Payer Coverage Policies on Genomic Sequencing Tests: Beginning of the End or End of the Beginning? JAMA. 2018;319(23):2379-2380.

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. 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

  16. 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.

  17. 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.

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  23. 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.

  24. 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.

  25. 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.

  26. 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.

  27. 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.

  28. 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.

  29. 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.

  30. Phillips KA. Closing the Evidence Gap in the Use of Emerging Testing Technologies in Clinical Practice. JAMA. 2008;300(21):2542-4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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