New TRANSPERS Study Identifies Opportunities to Resolving Reimbursement Challenges for Genetic Panel Tests for Cancer Risk Assessment

A recently published study—Payer Coverage for Hereditary Cancer Panels: Barriers, Opportunities, and Implications for the Precision Medicine Initiative—in the Journal of the National Comprehensive Cancer Network (2017:15(2) 219-228) used data from payers themselves to address not only reimbursement challenges but also opportunities for resolving those challenges.

Hereditary Cancer Panels - testing for multiple genes and syndromes - are rapidly transforming cancer risk assessment but are controversial and lack formal insurance coverage. Understanding payers' coverage decision-making is critical for clarifying the reimbursement status for patients and physicians, informing genetic research, and ultimately enabling access to these potentially transformative modalities.

Our study of private payers found a number of barriers to coverage for hereditary cancer panels, including poor fit with coverage frameworks, insufficient evidence, and departure from pedigree/family history-based testing toward population-based genetic screening. Opportunities for addressing these challenges includes refining target populations , developing evidence of actionability and pathogenicity/penetrance, creating infrastructure and standards for informing and re-contacting patients, separating research from clinical use in the hybrid clinical-research setting, and adjusting coverage frameworks.

Our findings have particular relevance to the National Institute of Health's Precision Medicine Initiative (PMI), which will assemble and study an unprecedented cohort of one million or more volunteers who will contribute genomic, clinical and lifestyle data to accelerate genetic science. Our article discusses how our findings may inform the implementation of this important initiative.