TRANSPERS Program on Coverage and Reimbursement: Understanding Payer Decision-Making

Insurance coverage is crucial to integrating precision medicine into practice and policy. Payers' decisions impact research, evidence, and adoption of new genomic technologies. However, in the U.S., diverse payer coverage can lead to variability and unequal access.

There’s a gap in understanding what influences payers’ decisions and the evidence they need, which varies across payers and testing methods. Payers cite insufficient clinical utility evidence as the primary barrier to coverage and interpret what constitutes sufficient evidence differently. The complexity of multigene tests challenges existing coverage frameworks, and policy differences can limit access, especially for underserved groups. Few forums exist for objective discussion on payer decisions, as advisory boards often serve commercial interests rather than independent research.

To address this gap, we assembled the UCSF TRANSPERS Payer Research 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 on health representing self-insured employers
  • Laboratory benefit management companies
  • Experts in public and private payer policies

Our research program is conducted using two methods:

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

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Accomplishments

Our research reveals critical insights into payer decision-making. This work has resulted in numerous highly cited peer-reviewed publications in major journals, including Genetics in Medicine and Value in Health, which are used by researchers, payers, industry, organizations, and venture capital firms. Our studies include coverage for genetic testing and genome sequencing across a wide range of areas, including cancer, newborn and pediatric care, prenatal care, and rare diseases.

We continue pioneering research on emerging genomic technologies. Our 2023 Health Affairs Scholar paper was among the first to examine payer perspectives on multicancer early detection (MCED) tests - one of the most promising yet challenging innovations in cancer screening, capable of detecting over 50 types of cancer from a single blood draw. This widely cited work revealed the unique complexities these breakthrough technologies pose for coverage decisions. Building on this foundation, our 2025 JCO Precision Oncology article identified key factors shaping cancer genomics coverage and opportunities to enhance equitable access. Our findings are already informing discussions among payers and policymakers. Additional publications include:

  1. Trosman JR, Weldon CB, Kurian AW, Mrig E, Phillips KA. Implementation of Cancer Genomics in the United States: Views of Payers and Other Stakeholders on Challenges and the Role of Payers in Solutions. JCO Precis Oncol. 2025 Feb;9:e2400822. doi: 10.1200/PO-24-00822. Epub 2025 Feb 28. PMID: 40020207; PMCID: PMC11875457.

  2. Trosman JR, Weldon CB, Kurian AW, Pasquinelli MM, Kircher SM, Martin N, Douglas MP, Phillips KA. Perspectives of private payers on multicancer early-detection tests: informing research, implementation, and policy. Health Aff Sch. 2023 Jun 20;1(1):qxad005. doi: 10.1093/haschl/qxad005. PMID: 38756840; PMCID: PMC10986216.

  3. Phillips KA, Trosman JR, Douglas MP, Gelb BD, Ferket BS, Hindorff LA, Slavotinek AM, Berg JS, Russell HV, Devine B, Greve V, Smith HS. US private payers' perspectives on insurance coverage for genome sequencing versus exome sequencing: A study by the Clinical Sequencing Evidence-Generating Research Consortium (CSER). Genet Med. 2022 Jan;24(1):238-244. doi: 10.1016/j.gim.2021.08.009. Epub 2021 Nov 30. PMID: 34906461; PMCID: PMC8962136.

  4. 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 Feb;22(2):283-291. doi: 10.1038/s41436-019-0650-7. Epub 2019 Sep 10. PMID: 31501586; PMCID: PMC7004856.

  5. Phillips KA, Trosman JR, Weldon CB, Douglas MP. New Medicare Coverage Policy for Next-Generation Tumor Sequencing: A Key Shift in Coverage Criteria With Broad Implications Beyond Medicare. JCO Precis Oncol. 2018;2:PO.18.00206. doi: 10.1200/PO.18.00206. Epub 2018 Nov 8. PMID: 31073549; PMCID: PMC6503521.

  6. 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 Feb;15(2):219-228. doi: 10.6004/jnccn.2017.0022. Epub 2017 Feb 10. PMID: 28188191; PMCID: PMC5508568.

  7. Trosman JR, Weldon CB, Douglas MP, Deverka PA, Watkins JB, Phillips KA. Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies. Value Health. 2017 Jan;20(1):40-46. doi: 10.1016/j.jval.2016.09.2402. PMID: 28212967; PMCID: PMC5319741.

  8. Trosman JR, 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. doi: 10.6004/jnccn.2015.0043. PMID: 25736008; PMCID: PMC4372087.

  9. Trosman JR, Van Bebber SL, Phillips KA. Health technology assessment and private payers's coverage of personalized medicine. Am J Manag Care. 2011 May;17 Suppl 5 Developing:SP53-60. PMID: 21711078.

  10. Trosman JR, Van Bebber SL, Phillips KA. Coverage policy development for personalized medicine: private payer perspectives on developing policy for the 21-gene assay. J Oncol Pract. 2010 Sep;6(5):238-42. doi: 10.1200/JOP.000075. PMID: 21197187; PMCID: PMC2936466.

Future Directions

We are continually advancing our research on insurance coverage decision-making to establish an unprecedented convening space for payers, patients, providers, researchers, and stakeholders in precision medicine, where diverse perspectives can be shared and solutions developed to improve decision-making and coverage policies.

Learn more about our work

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