Posters from the Academy of Managed Care Pharmacy Nexus 2021 meeting detailed how coverage of genetic testing aligns with current guidelines as well as the potential budget impact of expanding access to comprehensive genomic profiling (CGP).
Posters from the Academy of Managed Care Pharmacy Nexus 2021 meeting explored whether current health care coverage of biomarker testing using comprehensive genomic profiling (CGP) is in line with recommendations from the National Comprehensive Cancer Network (NCCN) as well as the potential budget implications of expanding access to CGP testing for patients with colorectal cancer.
Analysis of Health Coverage Policies and Alignment With NCCN1
Health plan coverage policies for multi-gene panel testing (MGPT) varied in how much they aligned with NCCN guidelines regarding biomarker testing coverage for select tumors, investigators concluded.
Coverage limitations due to panel size or tumor were common and may have been caused by ambiguity in the language used for the recommendations and/or lack of panel size recommendations in the NCCN guidelines. The investigators said that more clarification in guidelines recommendation could help guide and direct future health plan coverage policies.
Biomarker testing for somatic mutations, such as MGPT, is of growing interest to researchers as it can be used to inform cancer management decisions. However, studies have shown that insurance coverage policies limit patient access to biomarker testing and there is a limited understanding regarding how health plans cover MGPT in alignment with recommended guidelines from the NCCN.
The investigators reviewed commercial coverage policies for MGPT for 14 payers and NCCN guidelines for MGPT for 6 cancers: prostate, non-small cell lung cancer (NSCLC), breast, melanoma, colon, and thyroid. The results showed that NSCLC, melanoma, prostate, and breast tumors had recommendations in line with NCCN. Eight (57%) health plans were considered more restrictive than NCCN guidelines and 6 (43%) were consistent or less restrictive. Of the plans considered more restrictive than NCCN, 62.5% had panel size recommendations and 62.5% had restricted testing coverage to select or all tumors.
Budget Impact of Expanded CGP Testing Within Colorectal Cancer Population2
Expanding access to CGP testing by replacing 20% of usual testing with CGP testing was found to be associated with a small incremental testing cost but could identify actionable alternations for a meaningful number of patients, investigators concluded. Currently, CGP testing is limited in first-line settings for patients with mCRC.
The investigators used a decision analytic model to compare testing scenarios over a 2-year time period to assess current first-line testing with a mix of CGP and non-CGP diagnostics vs replacing 20% of usual testing with Tempus CGP testing. Cost components examined included initial and repeat testing, physicians-associated, and administrative costs.
The results showed that in a hypothetical 5 million-member health plan with a 50/50 split between Medicare and commercial insurance beneficiaries, 1112 incident cases of mCRC are expected in any given year, 556 of whom are expected to undergo first-line molecular diagnostic testing. Additionally, there are 521 missed opportunities for genomically-informed treatment annually, 442 of which are missed dure to lack of testing and 79 are due to testing without CGP.
Replacing 20% of usual testing with CGP testing was associated with up to a $0.003 per member per month testing cost and increase an additional 15.5 opportunities for genomically-informed care. For every first-line patient with advanced metastatic colorectal cancer (mCRC) that was tested using the Tempus CGP test rather than the usual mix of molecular testing, 1 additional patient that could receive treatment for identified actionable mutations.