Cancer 2017

Many Health Plans Avoid Paying For Prostate Cancer Genetic Tests

One reason is that they figure that CMS will foot the bill because many of their beneficiaries age into Medicare. Also, for every insurer: churn, churn, churn.

Joseph Burns
Contributing Editor

Churn. That’s the term health insurers use to describe how members move from one plan to another and from one insurer to another. Health plan administrators know that churn could make a big investment in health one year meaningless if that member has lower costs at another plan in the coming years.

Administrators also know that—like most everything in health care—there’s a way to turn a negative into a positive and use churn to your advantage. You simply don’t pay for expensive testing for a health plan member you know will shift to a different health insurer in the near future. And, in particular, if your plan has a number of members in their early 60s, you know they will age into Medicare soon so you might have an incentive to curtail coverage for services that will soon be on the government’s dime.

The buck doesn’t stop here

This is a game some insurers are playing with prostate cancer tests, says Elai Davicioni, PhD, president and chief science officer of GenomeDX. Urologists use the company’s Decipher Biopsy and Decipher Post Surgery tests to assess the chances that a low-risk prostate cancer will metastasize. According to Davicioni, health plan executives have told GenomeDX’s sales staff that they prefer not to cover these tests because soon enough these patients will become eligible for Medicare.

A February 2017 report from Piper Jaffray, a Minneapolis investment company, lends some credence to their claims. The company said that it tracked how 49 health insurers cover Oncotype Dx Prostate from Genomic Health. The report says the insurers either had no coverage policy or considered Genomic Health’s Oncotype DX Prostate test to be investigational or experimental.

Here’s where churn comes in: CMS has a program to determine the clinical utility and clinical validity of certain molecular diagnostic tests. Called MolDx, this program has reviewed the prostate cancer tests of GenomeDX, Genomic Health, and Myriad Genetics and decided that Medicare, at least in the region Palmetto GBA serves, should cover those tests. Many, though not all, of the other Medicare administrative contractors, follow Palmetto’s guidance on this issue, Daviocioni says.

As a result of the standards set by Palmetto, genetic test developers need to show that their tests have a direct bearing on treatment decisions if they’re hoping for Medicare coverage. So why don’t the private payers follow suit? asks Daviocioni.

Regulatory oversight of molecular tests is lacking, and studies of the test are poorly designed, says Phillip Krebs of Geisinger Health Plan.

Phillip Krebs, the director of medical policy for Geisinger Health Plan, has a simple answer: “If we had good evidence that one of those tests was a game changer, we’d be covering it. The reason most carriers see these tests as unproven is because there is a paucity of good quality evidence to prove otherwise.”

All three tests are likely more useful than assessing risk via a man’s prostate-specific antigen (PSA) test, Krebs acknowledges. But that’s not saying much. “At the end of the day,” says Krebs, “most of these tests are probably helpful in counseling patients, but none of them can determine an outcome with certainty.”

And while Palmetto’s MolDx program is a welcome addition to the growing field of companies reviewing the clinical utility of molecular tests, its assessments often do not align with that of other companies evaluating genetic tests, such as Hayes and ECRI, Krebs says. What’s more, Palmetto doesn’t publish the data on its assessments, making it difficult to assess the reasoning behind its decisions, he says. Krebs says there’s a general problem of lack of regulatory oversight of molecular tests and poorly designed studies.

While private payers wait for more data, Davicioni says men with prostate cancer must pay about $3,000 out of pocket for genetic tests—or wait till they are old enough for Medicare coverage. Meanwhile, these men risk developing a deadly metastasized form of cancer, driving up the costs of Medicare coverage, according to Davicioni.

“Prostate cancer is unique in that the risk of getting more aggressive prostate cancer increases with age,” Davicioni says.

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