Insurance companies are making it mandatory for individuals to speak with qualified genetic counselors prior to testing for some hereditary cancers.
Genetic screening, particularly in individuals who have a known family history of cancer, could help early diagnosis or weed out uncertainty. However, incompetence could lead to wrong and sometimes unnecessary testing. Herein lies the crux of the issue: at what point do genetic counselors need to step in? Should counselors assist physicians and oncologists in interpreting test results and make treatment decisions, or should their advice be pursued pre-testing?
There seem to be 2 differing views here, according to a report by Kaiser Health News (KHN), particularly when it comes to gynecological cancers. Obstetrician-gynecologists interviewed by KHN believe that medical school training prepares them to counsel patients on family history of diseases, including cancer. “This is what we do. There are simple-to-understand criteria for who should be considered for genetic testing, and it usually has to do with whether you or someone in your family has had cancer,” Mark S. DeFrancesco, MD, who served as the president of the American Congress of Obstetricians and Gynecologists for 2015-2016, told KHN. He believes that patients may oftentimes forego testing if forced to see a genetic counselor.
Payers seem to believe otherwise. In 2013, insurance giant Cigna made genetic counseling a requirement for BRCA testing (breast cancer) and also for hereditary colorectal cancer syndromes. Beginning in July this year, Cigna’s Genetic Testing and Counseling Program made genetic counseling mandatory prior to testing for all forms of hereditary cancers. According to the company website, the counselors can assist with the overall testing process by supporting individuals prior to and after genetic testing, in addition to helping the ordering physician.
UnitedHealthcare has followed suit for BRCA testing. Beginning in January 2016, the company started enforcing counseling by a qualified genetic counselor prior to testing for risk of hereditary breast and ovarian cancer.
Opposing this move, The American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists together released a statement last year that stated that the prior authorization requirements set by insurers “only make it harder for patients to get the care they need at a time when delays may lead to worse outcomes.”
Cigna has not ruled out counseling by physicians, however. Jeffrey F. Hankoff, MD, medical officer for performance and quality, Cigna, told KHN that physicians who get additional training in cancer genetics could fill in as genetic counselors for Cigna members seeking testing.
According to Joy Larsen Haidle, MS, CGC, physicians can feel overwhelmed by the growing number of genetic tests in the market. At the Patient-Centered Oncology Care meeting in Baltimore last year, the 2015 president of the National Society of Genetic Counselors told the audience that genetic counselors can help doctors take advantage of new discoveries in the field while simultaneously avoiding wasteful spending on unnecessary tests.
During her presentation, Larsen Haidle shared data showing that genetic counseling can reduce the number of inappropriate genetic tests from more than a quarter of all tests performed to well under 5% of all tests. “We know that the current system is not working, with 30% of the tests not being ordered appropriately. It really is imperative that all of us are working together to do a better job,” she said.