UCSF

TRANSPERS Program on Coverage and Reimbursement: Systematic Reviews of Payer Coverage Policies

A major focus of the TRANSPERS Center is coverage, reimbursement, and policy decisions by payers on Precision Medicine. There is no publicly available source that compiles and compares coverage policies across payers and thus there is a gap in understanding what genomic tests are covered by payers. To address this gap, we conduct systematic reviews of payer coverage policies to assess which tests are covered by payers, what factors are discussed in policies, and how coverage policies vary across clinical scenarios, populations, and payers.

We examine a range of coverage policies across multiple private and public payers and pertaining to a broad range of tests and testing indications. We have conducted payer coverage analyses on BRCA1/2, non-invasive prenatal testing, hereditary cancer panels, exome sequencing in pediatric patients, tumor sequencing, and circulating tumor DNA in cancer.

We use a systematic and validated approach:

  • identify and obtain publicly available policies from payer websites
  • abstract key variables including coverage/noncoverage
  • detailed clinical indications
  • specific tests covered
  • analyze coverage by clinical indications, specific tests, and payer types.

PDF iconPrintable Summary: Policy Systematic Reviews (PDF)

Accomplishments

Since 2015, our research has resulted in numerous peer-reviewed publications in major journals. Our work has been widely cited and used by researchers, payers, industry, organizations, and clinicians. We are continuing to work on novel genomic technologies as they emerge. In one instance, our 2020 paper in Journal of National Comprehensive Cancer Network addressed private and Medicare coverage policies for circulating tumor DNA testing for cancer management. Additional publications include:

  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. Journal of the National Comprehensive Cancer Network. 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. Douglas MP. Parker S. Trosman JR. Slavotinek AM. Phillips KA. Private Payer Coverage Policies for Whole Exome Sequencing (WES) in pediatric patients: trends over time and analysis of evidence cited. Genet Med. 2019;21(1):152-160.
  4. Trosman J, Weldon C, Douglas M, Kurian A, Kelley R, Deverka P, et al. Payer Coverage of Hereditary Cancer Panels: Barriers, Opportunities, and Implications for the Precision Medicine Initiative. Journal of the National Comprehensive Cancer Network; 2017:15(2):219-228.
  5. Dervan A, Deverka PA, Trosman JR, Weldon CB, Douglas MP, Phillips KA. Payer Decision-Making for Next Generation Sequencing-Based Genetic Tests: Insights from Non-Invasive Prenatal Screening. Genet Med. 2017:19(5):559-567.
  6. Phillips KA, Trosman JR, Weldon CB, Chambers J, Deverka PA, Douglas MP. Payer coverage policies for multigene tests. Nat Biotechnol. 2017:35(7):614-617.
  7. Chambers J, Saret C, Anderson J, Deverka PA, Douglas MP, Phillips KA. Examining Evidence in U.S. Payer Coverage Policies for Multi-Gene Panels and Sequencing Tests. Int J Technol Assess Health Care. 2017:33(4):534-540.
  8. Clain E, Trosman JR, Douglas MP, Weldon CB, Phillips KA. Availability and payer coverage of BRCA1/2 tests and gene panels. Nat Biotechnol. 2015 Sep;33(9):900-2.

Learn more about our work

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